The small team, with technical data expertise, worked out of HHS’ Office of the Assistant Secretary for Planning and Evaluation, or ASPE. Their dismissal mirrored others across HHS, which came without warning and left officials puzzled as to why they were “RIF’ed” — as in “reduction in force,” the bureaucratic language used to describe the firings.

“I suspect they RIF’ed offices that had the word ‘data’ or ‘statistics’ in them,” said one of the laid-off employees, a social scientist whom KFF Health News agreed not to name because the person feared further recrimination. “It was random, as far as we can tell.”

Among those fired was Kendall Swenson, who had led development of the poverty guidelines for many years and was considered the repository of knowledge on the issue, according to the social scientist and two academics who have worked with the HHS team.

The sacking of the office could lead to cuts in assistance to low-income families next year unless the Trump administration restores the positions or moves its duties elsewhere, said Robin Ghertner, the fired director of the Division of Data and Technical Analysis, which had overseen the guidelines.

The poverty guidelines are “needed by many people and programs,” said Timothy Smeeding, a professor emeritus of economics at the La Follette School of Public Affairs at the University of Wisconsin. “If you’re thinking of someone you fired who should be rehired, Swenson would be a no-brainer,” he added.

Under a 1981 appropriations bill, HHS is required annually to take Census Bureau poverty-line figures, adjust them for inflation, and create guidelines that agencies and states use to determine who is eligible for various types of help.

There’s a special sauce for creating the guidelines that includes adjustments and calculations, Ghertner said. Swenson and three other staff members would independently prepare the numbers and quality-check them together before they were issued each January.

Everyone in Ghertner’s office was told last week, without warning, that they were being put on administrative leave until June 1, when their employment would officially end, he said.

“There’s literally no one in the government who knows how to calculate the guidelines,” he said. “And because we’re all locked out of our computers, we can’t teach anyone how to calculate them.”

ASPE had about 140 staff members and now has about 40, according to a former staffer. The HHS shake-up merged the office with the Agency for Healthcare Research and Quality, or AHRQ, whose staff has shrunk from 275 to about 80, according to a former AHRQ official who spoke on the condition of anonymity.

HHS has said it laid off about 10,000 employees and that, combined with other moves, including a program to encourage early retirements, its workforce has been reduced by about 20,000. But the agency has not detailed where it made the cuts or identified specific employees it fired.

“These workers were told they couldn’t come into their offices so there’s no transfer of knowledge,” said Wendell Primus, who worked at ASPE during the Bill Clinton administration. “They had no time to train anyone, transfer data, etc.”

HHS defended the firings. The department merged AHRQ and ASPE “as part of Secretary Kennedy’s vision to streamline HHS to better serve Americans,”  spokesperson Emily Hilliard said. “Critical programs within ASPE will continue in this new office” and “HHS will continue to comply with statutory requirements,” she said in a written response to KFF Health News.

After this article published, HHS spokesperson Andrew Nixon called KFF Health News to say others at HHS could do the work of the RIF’ed data analysis team, which had nine members. “The idea that this will come to a halt is totally incorrect,” he said. “Eighty million people will not be affected.”

Secretary Robert F. Kennedy Jr. has so far declined to testify about the staff reductions before congressional committees that oversee much of his agency. On April 9, a delegation of 10 Democratic members of Congress waited fruitlessly for a meeting in the agency’s lobby.

The group was led by House Energy and Commerce health subcommittee ranking member Diana DeGette (D-Colo.), who told reporters afterward that Kennedy must appear before the committee “and tell us what his plan is for keeping America healthy and for stopping these devastating cuts.”

Matt VanHyfte, a spokesperson for the Republican committee leadership, said HHS officials would meet with bipartisan committee staff on April 11 to discuss the firings and other policy issues.

ASPE serves as a think tank for the HHS secretary, said Primus, who later was Rep. Nancy Pelosi’s senior health policy adviser for 18 years. In addition to the poverty guidelines, the office maps out how much Medicaid money goes to each state and reviews all regulations developed by HHS agencies.

“These HHS staffing cuts — 20,000 — obviously they are completely nuts,” Primus said. “These were not decisions made by Kennedy or staff at HHS. They are being made at the White House. There’s no rhyme or reasons to what they’re doing.”

HHS leaders may be unaware of their legal duty to issue the poverty guidelines, Ghertner said. If each state and federal government agency instead sets guidelines on its own, it could create inequities and lead to lawsuits, he said.

And sticking with the 2025 standard next year could put benefits for hundreds of thousands of Americans at risk, Ghertner said. The current poverty level is $15,650 for a single person and $32,150 for a family of four.

“If you make $30,000 and have three kids, say, and next year you make $31,000 but prices have gone up 7%, suddenly your $31,000 doesn’t buy you the same,” he said, “but if the guidelines haven’t increased, you might be no longer eligible for Medicaid.”

The 2025 poverty level for a family of five is $37,650.

As of October, about 79 million people were enrolled in Medicaid or the related Children’s Health Insurance Program, both of which are means-tested and thus depend on the poverty guidelines to determine eligibility.

Eligibility for premium subsidies for insurance plans sold in Affordable Care Act marketplaces is also tied to the official poverty level.

One in eight Americans rely on the Supplemental Nutrition Assistance Program, or food stamps, and 40% of newborns and their mothers receive food through the Women, Infants, and Children program, both of which also use the federal poverty level to determine eligibility.

Former employees in the office said they were not disloyal to the president. They knew their jobs required them to follow the administration’s objectives. “We were trying to support the MAHA agenda,” the social scientist said, referring to Kennedy’s “Make America Healthy Again” rubric. “Even if it didn’t align with our personal worldviews, we wanted to be useful.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

A week into the reorganization of the Department of Health and Human Services announced by Secretary Robert F. Kennedy Jr., the scope of the staff cuts and program cutbacks is starting to become clear. Among the biggest targets for reductions were the nation’s premier public health agencies: the Centers for Disease Control and Prevention, the National Institutes of Health, and the FDA.

Meanwhile, Kennedy did not show up as invited to testify before the Senate Health, Education, Labor and Pensions Committee, known as HELP, but he did visit families in Texas whose unvaccinated children died of measles in the current outbreak and called for an end to water fluoridation during a stop in Utah.

This week’s panelists are Julie Rovner of KFF Health News, Victoria Knight of Axios, Alice Miranda Ollstein of Politico, and Sandhya Raman of CQ Roll Call.

Panelists

Victoria Knight
Axios

@victoriaregisk

Read Victoria's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Sandhya Raman
CQ Roll Call

@SandhyaWrites

Read Sandhya's stories.

Among the takeaways from this week’s episode:

• Amid a dearth of public information about federal health cutbacks, HHS employees currently on administrative leave report they were given no opportunity to hand off their responsibilities, suggesting important work will simply be discontinued. Critical staff members have been cut from the FDA offices funded by user fees, for instance — affecting the drugmakers that pay the fees in exchange for timely evaluation of their products, as well as the patients hoping for access to those drugs. Even if the cuts were reversed, the damage could linger, especially in areas where there will be gaps in data such as disease surveillance.
• Meanwhile, the temporary public communications freeze implemented in the Trump administration’s early days apparently has not ended. State officials, desperate for information from federal health officials about ongoing programs, are receiving no response as they seek guidance from offices in which most or all staffers were laid off.
• President Donald Trump issued an executive order this week that instructs federal department heads to summarily repeal any regulation they deem “unlawful.” The order threatens to effectively short-circuit the federal regulatory process, which involves public notices and opportunities to comment. Businesses rely on that process to make decisions, and Trump’s order could create further instability for health care and other industries.
• And Kennedy traveled West this week, using his public appearances to call for removing fluoride from the water supply and to discuss the measles outbreak. He issued his strongest endorsement of the measles vaccine yet, but he also praised doctors who have used alternative and unapproved remedies to treat measles patients. Senators had called him to testify before Congress this week about the ongoing upheaval at HHS, but the hearing was canceled.
• Legislators in a growing number of states are introducing abortion bans that would punish women seeking abortions as well as abortion providers, suggesting a long game for abortion opponents that goes well beyond overturning a nationwide right to the procedure.

Also this week, Rovner interviews Georgetown Law School professor Stephen Vladeck about the limits of presidential power.

Plus, for “extra credit” the panelists suggest health policy stories they read (or wrote) this week that they think you should read, too: 

Julie Rovner: The New York Times’ “Why the Right Still Embraces Ivermectin,” by Richard Fausset.  

Victoria Knight: Wired’s “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall,” by Leah Feiger and Steven Levy.  

Alice Miranda Ollstein: The Guardian’s “‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training,” by Carter Sherman.  

Sandhya Raman: CQ Roll Call’s “In Sweden, a Focus on Smokeless Tobacco,” by Sandhya Raman. 

Also mentioned in this week’s podcast:

• The New York Times’ “The Three States That Are Especially Stuck if Congress Cuts Medicaid,” by Sarah Kliff and Margot Sanger-Katz.
• The AP’s “Ex-Official Says He Was Forced out of FDA After Trying To Protect Vaccine Safety Data From RFK Jr.,” by Matthew Perrone.

Click to open the transcript

Transcript: The Dismantling of HHS

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 10, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Sandhya Raman of CQ Roll Call. 

Sandhya Raman: Good morning, everyone. 

Rovner: And Victoria Knight of Axios news. 

Victoria Knight: Hello, everyone. 

Rovner: Later in this episode we’ll have my interview with Georgetown University law professor Stephen Vladeck, who will talk about the limits of presidential power — if there are any left. But first, this week’s news. 

So the dust is starting to settle, sort of, in that ginormous reorganization of the Department of Health and Human Services launched by Secretary Robert F. Kennedy Jr. last week, which I am now calling “The Great Dismantling.” Here’s some of what we know about the casualties at the CDC [Centers for Disease Control and Prevention]. Offices that worked on sexually transmitted disease prevention, injury prevention, lead poisoning surveillance, and tobacco were basically gutted. At NIH [the National Institutes of Health], the chronic pain division was eliminated, as was the Office of Long Covid. And at the FDA [Food and Drug Administration], offices handling veterinary medicine, generic drugs, and food safety were dramatically reduced. Now that we’ve had a week to absorb what’s been done and, despite claims of the contrary from Secretary Kennedy, we are told there is no plan to hire back some of those workers who were apparently let go in error, what are you guys hearing about where we are? 

Ollstein: Yeah, there’s a lot of people who were put on administrative leave, which is going to run out in a few weeks. By and large, they are not expecting to be called back. They are holding out hope. They would love to be called back. They keep telling me that they would love to get back to the work they were doing. They’re really worried about it not continuing without them, but they’re mostly assuming that these cuts are permanent for now. And contrary to claims from HHS that work isn’t being eliminated, it’s just being consolidated or folded in or there’s different words they’re using, all of these different laid-off workers told me from different divisions that they were basically given no opportunity to hand over their ongoing projects to anyone else, to train anyone else, to make sure it keeps going. So as far as they know, a lot of this surveillance work, research work, coordination work is just not going to be happening going forward. 

Rovner: As far as I can tell, money that’s supposed to be going out the door from places like the NIH isn’t. 

Knight: Yeah, you hit some of the offices, programs that have been cut, but also I think at FDA, we did some reporting this week on the user drug fee program and how staff that do the evaluating drugs and things like that have been cut. And it’s interesting because pharmaceutical companies pay these fees hoping that they’ll get timely evaluations of their drugs, and also— 

Rovner: They pay these fees and are told they will get timely evaluation of these drugs in exchange. That’s the deal. 

Knight: Exactly. And I know pharmaceutical companies are definitely concerned about this, and it’s also concerning for patients who may be waiting for certain drugs to be approved and things like that. And I think it’s interesting, also, Republicans like to talk a lot about innovation and getting new drugs approved and things like that, and this would harm that process if the staff are not rehired. I haven’t really heard an update on that, so— 

Raman: I would also add that part of it is that we just don’t have a lot of information, right? We had Secretary Kennedy invited to come testify before the Senate HELP Committee this week and go through some of these things and explain the rationale and get into that, and that did not happen. 

Rovner: Yeah, we’ll get to that. 

Raman: Yes, and I think, at the same time, a lot of those cuts were also to the communications folks within those agencies that could be disseminating this information to external folks, to internal folks to provide more clarity about where things would be going. And we don’t have those there now, so it will take some time to kind of see where things are going, and even when there’s going to be a delay in some of that stuff, getting that information out is going to be difficult. 

Ollstein: Sandhya is absolutely right about the communications issue here, and I’m just hearing that on so many fronts. States are desperate to get in contact with someone in the federal government to understand what’s going on. Do they have to keep collecting data and sending it to the federal government even though there’s no one left to compile and process it? They’re reaching out asking: Are certain grants going to continue or not? What should we do? Are we going to be in legal trouble if we continue some of this work? And there’s just no one answering, sometimes because all the people that would’ve answered have been let go. But also the communications freeze that was supposed to be temporary at the very beginning of the administration, a lot of federal workers told me that never really ended. 

So there are these email accounts that they were ordered to stop checking and responding to. So one example is the entire team that worked on IVF [in vitro fertilization], evaluating which IVF clinics had the best pregnancy success rates, monitoring safety, all of that — they were all eliminated. And one consequence of that is that there was this email account that doctors, patients, anybody could reach out to for information and to ask questions, and no one’s checking it, no one’s responding. 

Rovner: I don’t know about you guys. I am starting to hear from health care stakeholders. The federal government is so intertwined in, basically it’s a fifth of the economy, what we spend on health care, and it’s creating so much uncertainty. As you were saying, people don’t know if they’re going to get in trouble for not doing things or for doing things. But we do know, as we said, we talked about last week, FDA missed a deadline to rule on a Novavax vaccine. This is going to have ramifications way beyond just the people who are losing their jobs in the federal government, right? 

Raman: There’s so many people that receive the services that we contract out, that we put grants through across the country. And I think that even in speaking to some of these employees that have lost their jobs, one of the top concerns is not even for their own job but that no one else can do the work that they did. Or in some cases, the only person that could have done that work has also already been let go. And just that those things are going to fall through the cracks for a lot of vulnerable communities. 

Ollstein: Some of the folks also told me that even if this is reversed in the future, the damage will just be there for a very long time, especially on things like surveillance and data collection. If you have a gap in there, that skews things. That messes things up for the future. It makes it harder to make comparisons. It makes it harder to know if things are getting better or worse on, like, asthma rates and levels of lead in people’s blood, all kinds of things, things that are not politically controversial or partisan. And so it’ll just be really difficult going forward to know which programs are working, which interventions are working or not working. 

Rovner: So things are happening almost too fast to keep track of. But in his latest round of executive orders on Wednesday, President [Donald] Trump signed one called Directing the Repeal of Unlawful Regulations, in which he basically instructs the heads of all departments to repeal rules they consider unlawful, without notice or comment, which is not how this is supposed to work. I’m not sure even, though, quite what to make of all this. And it seems to be going mostly unnoticed in all of the attention, deservedly, to the other news that’s happening, some of which we’ll get to. But repealing rules basically on a whim could be as important to how the federal government functions as firing all these people, right? 

Raman: Yeah, there’s a reason that the rulemaking process is the way it is, that it takes a certain amount of time. You allow stakeholders to weigh in, to meet, to revise, and that the things aren’t changing too drastically. And there are some rules that go back and forth between the administrations, but a lot of things last over time, and the process is the way it is to make sure that you get the best possible result for whatever you’re changing and— 

Rovner: That you get stability. 

Raman: Yes. 

Rovner: I think that’s the theme here, is that that’s what we’re lacking right now. Nobody can count on what the rules are. 

Knight: And I was going to say, from an industry perspective, industries make decisions based on these rules and knowing when they’re going to come out and when they might change. Think about the insurance industry, physicians, people within the health care industry. And so that could really impact those groups as well a lot. So, and exactly, going back to what you said about stability, so it’ll make it really hard to make business decisions. 

Rovner: Right. So this goes along with the stuff with the tariffs, is that we have no idea what the rules of the road are going to be going forward if rules can be sort of disappeared in a matter of days the way staff is being. Well, let’s move to Congress. Remember Congress? Late last Friday, or I guess it was technically early Saturday, the Senate passed what was supposed to be a compromise Republican budget resolution between the House and the Senate. For those who have forgotten, while the House passed a resolution that would lead to a single gigantic budget reconciliation bill, including tax cuts and likely big cuts to Medicaid, the Senate’s original budget resolution would only have led to a bill on immigration and energy, saving the tax and health fights for later in the year. 

Well, it seems like the compromise, which is kind of a vaguer version of the House blueprint, didn’t go over so well in the House, where Speaker Mike Johnson had hoped to push it through this week. A vote was scheduled for Wednesday, then it got delayed, then it got shelved, at least for the night. They’re apparently trying to regroup and do this this morning. Where are we in this? 

Knight: Yeah, so you gave a pretty good rundown. I was here late last night talking to Freedom Caucus members, the House Freedom Caucus, the hard-liners. Their concerns with, this is basically a Senate amendment to the House’s resolution. And so what the Senate passed was an amendment, and it technically really just gives instructions for the Senate. It didn’t touch the House’s resolution. So the House’s budget resolution they passed is the same thing, but House Freedom Caucus members had issue that the Senate ceilings for cuts is much lower than the House’s. And so they’re saying— 

Rovner: It’s in the billions instead of trillions. 

Knight: Exactly. Exactly. So coming out, they holed up with Speaker Johnson last night and House GOP leadership and were saying, We need more binding cuts on the Senate side, and were like: We need you guys to commit to this, otherwise we’re unhappy with this amount of cuts. This is going to increase spending. There’s been a lot of discussion on how to do the budget math for these things, but it’s pretty clear the Senate’s resolution would not cut spending as much as the House’s. So that was what they came out demanding last night. This morning, Speaker Johnson and Senate Majority Leader John Thune came out, did a press conference, and said: We’re going to proceed with this. We’ll see if that changes. But it was interesting to note that Thune said, he noted that there are Senate Republicans that do want cuts that may be up to the $1.5 trillion, but he did not commit to making cuts on his side. So we’ll see how this goes. That seems to be the state of play. It’s very in flux. That could change over time. So if anyone has anything to add, I think that’s a rundown. 

Rovner: Yeah, it feels like they’re kind of buying time to see if they can keep together what’s clearly a very fractious group here. 

Knight: Yeah, and jet fumes are always a good motivator, and also holidays. So there’s supposed to be a two-week recess right after this, and Passover starts this weekend and Easter next weekend, so we’ll see if that motivates people to vote for it. I will say, an argument that we’ve heard from a lot of the moderates that are concerned about the Medicaid cuts, when they voted for these, they’ve said: This is just an outline. It’s just a blueprint. It’s not committing us to anything. But hard-liners don’t seem to like that argument as much. So can they convince them that way? I don’t know. 

Rovner: Well, let’s talk about those Medicaid cuts for a minute, which, by the way, as you pointed out, Victoria, is not really what’s holding up the vote in the House. Our New York Times podcast pals Sarah Kliff and Margot Sanger-Katz had a really interesting story over the weekend about three red states that would really be stuck if Medicaid gets cut. Oklahoma, Missouri, and South Dakota all passed their Medicaid expansions by ballot measure, including it as part of their state constitutions. Now this is exactly the opposite of those states that would immediately cancel their expansions if Congress cuts the Medicaid match. These three states would be totally stuck, unless they could have another ballot measure that would then eliminate what they added. I guess that helps explain why very conservative Missouri Republican Sen. Josh Hawley says he is so opposed to reducing the Medicaid match. But he seems OK with Medicaid work requirements that would also cut people off the rolls, just not necessarily in a way that would cost the state so much money, right? 

Ollstein: Yeah, I think we’re going to see a lot of interesting semantic games going forward. I think we’re going to see a lot of different interpretations of what a cut is. We’re going to see a lot of claims made about who does and doesn’t deserve Medicaid coverage. We’ve been seeing this for a long time, but as these tough decisions have to be made on the Hill, I think a lot of that is going to come to a head. And so I think you see a lot of conservatives wrestling with believing very strongly in cutting government spending but also recognizing that a lot of their constituents could be harmed by these policies and they would be very angry with their members if that happened. 

And so trying to thread that needle, we’ll see how they do it, whether they can do it successfully without getting a lot of political blowback. Even though there has been a lot of turnover in Congress, you have a decent number of folks who were there last time Congress tried to take a big whack at Medicaid in the Affordable Care Act repeal fight. 

Rovner: In 2017. 

Ollstein: Exactly. Exactly. And the impact on Medicaid is one of the biggest things that garnered a backlash. And Capitol Hill was covered in folks with disabilities protesting, and it was a really bad look, and it contributed to that effort failing. 

Knight: And I think interesting talking about Hawley, but also the Republican Governors Association joined up with some other conservative groups this week to start an ad saying, Don’t cut Medicaid, basically. And so we’re starting to hear that from the states. States are really concerned how this could affect their budgets. They’ve already expanded the program. It would be really hard for them to have to make up in the state that amount of money if the federal government takes away money from the Medicaid program for them or caps it or whatever. It’s interesting to see people walk that line. And House GOP moderates, they are more likely to fold, I think, than hard-liners, but they keep telling me when I talk to them, We’re OK with work requirements, but anything past that might be really hard for us to vote for. But who knows? They could fold if they have enough pressure, but they’re trying to walk the line at this moment. 

Rovner: This is going to be a very different Medicaid fight than it was in 2017. Well, turning to this week in “Make America Healthy Again,” I think we mentioned last week that HHS Secretary RFK Jr. had been invited to testify before the Senate Health, Education, Labor, and Pensions Committee today. Well, as Sandhya pointed out, that did not happen. We’re not entirely sure why, but the secretary continues to do things, well, things he kind of promised senators that he wouldn’t, like saying that he’s going to order the CDC to stop recommending adding fluoride to public water supplies, which he did on a trip to Utah this week. Once more for those in the back, why do most public health professionals support water fluoridation? 

Raman: It really reduces dental decay, by like 25%. ADA [the American Dental Association] has been recommending fluoride for years. So it’s a big proponent of that. 

Rovner: And as someone pointed out, it’s against dentists’ interests to be recommending something that gives them less work and yet they’re still recommending it. 

Ollstein: And even though we have a very silly system in the U.S. where dental care is siloed off from the rest of health care, it does impact your overall health a lot. So it could lead to lung issues, heart issues, all kinds of things if you have dental issues. So it’s not just a cosmetic problem, it can be a very serious health problem. And I will say, too, people should keep in mind that there’s a lot of pointing at studies about negative health impacts from excessive consumption of fluoride, but those studies have a level that is much, much higher than what’s in the U.S. tap water right now. So anything in excess can be bad for you — even just plain water can kill you if you have too much of it. And so I think that people should keep that in mind and remain skeptical about claims being made. 

Rovner: Well, RFK Jr. also continues to make news in his handling of the measles outbreak in Texas, which is now the largest in the nation in the past 30 years, having sickened nearly 600 people, mostly unvaccinated children. Kennedy traveled to the heart of the outbreak last week and visited with the families of the two children that we know have died so far of the virus. He also praised the measles vaccine, but then just hours later posed with and praised two doctors who are using unapproved treatments for measles, including one who was disciplined by Texas medical regulators. Meanwhile, Peter Marks, the FDA vaccine official forced to resign last month, is speaking out, calling Kennedy’s actions thus far, quote, “very scary” in an interview with The Wall Street Journal and telling the AP [Associated Press] that he got fired for trying to keep Kennedy’s team from editing or possibly erasing the very sensitive Vaccine Adverse Event Reporting System kept by the FDA. Is there any way we didn’t see all of this coming? 

Knight: Well, going back to the congressional aspect. The HELP chair, [Sen.] Bill Cassidy, he had both the HELP hearing and the Senate Finance hearing where he questioned Kennedy repeatedly about his views on vaccines, his views on the link between vaccines and autism, I think also measles and autism. And he didn’t really ever get a super substantial answer from Kennedy. And yet the compromise was somewhat that Cassidy said, You’ll have to come quarterly before the HELP Committee and testify about what’s going on, what your views are. And we saw Cassidy try to do that last week. And Kennedy has, as far as I know, the latest is that he received the request but he hasn’t accepted it yet, and unclear if he will. 

So that congressional oversight was supposed to be the way to keep him in check, somewhat. And that’s not happening. It’s not really that enforceable. So I think it’s pretty predictable what’s happening. I think what will be interesting is if the White House gets unhappy with some of Kennedy’s things that he’s doing. There’s been some stories of how they’re having to take over his communications because there’s been no communications from HHS on it, and so they’re kind of unhappy with that. We’ll see if that reaches to a level where they could change leadership or something. But, not there yet, certainly, but something to watch. 

Rovner: Again, so much going on. I think this would normally rise to a higher level than it has given all of the other news that’s happening. Moving on to abortion. We talked last week, or maybe it was the week before, about the Overton window moving towards criminalizing women who have or even seek abortions. That’s apparently the point of a bill introduced in the Alabama Legislature. In North Carolina, a new bill could subject anyone convicted of performing or receiving an abortion to life in prison. We talked a few weeks ago about a similar bill in Georgia that got a legislative hearing. Even if none of these bills pass — and it seems that none of them will pass, at least this year — it certainly seems that claims by the anti-abortion movement that they don’t want to punish women are either not true or falling on deaf ears. 

Ollstein: So the anti-abortion movement, just like the pro-abortion-rights movement, is not a monolith. And just like the political parties, there are moderates and hard-liners. There are people who disagree on tactics. And so I think for so long the movement appeared united because their main goal was just overturning Roe v. Wade. And they were able to paper over other divisions by focusing pretty exclusively on that, or not exclusively but that being the overriding goal. And now that they’ve accomplished that and now that there are a lot more opportunities for them, you’re seeing these divisions. And we’ve seen that over the past few years. There were people who said, OK, a 15-week ban is better than nothing, and we can build on it. And there are people who say: No, that’s an unacceptable compromise, and it has to be a total ban or nothing. And if you do a 15-week ban, you’re endorsing the murder of most babies, because most abortions happen before 15 weeks of pregnancy. 

So I think this is a continuation of that. And it’s also a reflection that there is a lot of frustration in the anti-abortion movement that not only have abortions not ceased when states enact bans, in some cases they’ve gone up, nationally. And that’s a combination of people traveling, that’s a combination of people using telehealth and getting pills mailed to them. That’s become a huge thing that people rely on. And so looking at ways to crack down on those things, including this kind of criminalization of the pregnant patient that’s been sort of a third rail that is now more in the conversation. Of course, people have been proposing such things for a while now, but it’s getting more prominent attention than before. 

Rovner: Yeah. And that was my question, is it used to be a real outlier, and now we’ve seen legislation introduced in 10 states that would criminalize the woman in some way, shape, or form. Sandhya, you wanted to add something. 

Raman: I was going to say it’s also a long game. There are things that we’ve had proposed years ago that I think garnered attention then as being very outside the realm of something that people would consider. And then a few years later, when we first saw some of these personhood bills years ago, I think those got attention as being a little different than some of the other things that were being considered. And now that has become more mainstream. We see that in a lot of states now. And I think that something like this, even though it is very different than the messaging we’ve seen in the past, it doesn’t mean that, down the line, a greater portion of the movement pivots toward this. Because we’ve seen so much of this throw the spaghetti at the wall with seeing different things that they can see, what can pass, what doesn’t get litigated, that kind of thing. So a lot of this is kind of a long game. 

Ollstein: Yeah. And there is an imbalance between the two sides where the right is much more willing to throw spaghetti at the wall and see what sticks, much more willing to throw out things that could anger people, could generate controversy, could generate backlash, but they do believe will advance the goal. And you’re not really seeing the same willingness on the left. You’re not really seeing states propose, Let’s get rid of all abortion restrictions in total. And so you have this imbalance of what each side is willing to even consider, where the left has been, overall, not exclusively, but overall much more cautious and much more consensus-seeking. 

Rovner: Well, meanwhile, in Texas, where over the past few years we’ve had story after story about women with wanted pregnancies nearly dying from complications, the legislature finally has before it a compromise bill that would better define when doctors can end a doomed pregnancy without risking going to prison, except it’s turning out to be not as much of a compromise as its backers had hoped. Is there any way to actually find a compromise on what is a necessary abortion and what is saving the woman’s life? They write these things and they say: Well, look. Here are the exceptions, and they should work. But now they’re trying to spell out the exceptions and they can’t seem to agree on those, either. 

Ollstein: So it’s really a catch-22. And I was just in Texas. I was interviewing OB-GYNs, and they were explaining — and those in other states with bans have said the same thing — that, look, it’s really tough, because if a law is too broad and too vague, then doctors don’t feel comfortable doing even things they feel are absolutely medically necessary. But if a law is too prescriptive — if, for example, it tries to list every single possible condition that would necessitate an emergency abortion or an abortion to save someone’s life for health — you’re never going to be able to list everything. So many things can go wrong during a pregnancy, and so any attempt to be comprehensive will inevitably leave something out. And so if you go the route of listing specific conditions and someone comes in with a condition that’s not on the list, doctors won’t feel comfortable, because they’ll feel that, Oh, well, because the law lists these other conditions, that must mean that anything else is not allowed. 

But on the other hand, if it’s too vague, you have the opposite problem. And so really a lot of mainstream medical groups like ACOG, the American College of Obstetricians and Gynecologists, have really come down on, like: Just don’t legislate this at all. Just let us do our jobs. Because they are in this conundrum. I will say, there are divides within the medical community despite that, where some feel like, OK, well, if we can add a few more exceptions and that can even help a few more people, that’s at least something to consider, where others think, OK, no, if we endorse these quote-unquote “fixes,” that kind of in a way is endorsing the underlying ban, and we don’t want to do that. And so there’s some tension there as well. 

Rovner: Yeah, this is going to continue to be an issue going forward. All right, well, finally this week there is some other policy news. The Trump administration last week reversed a Biden administration decision to start covering those GLP-1 [glucagon-like peptide 1] drugs for people with obesity as well as those with diabetes. According to The New York Times, the administration didn’t attribute the decision to Secretary Kennedy’s known dislike of the drugs, which he has said are inferior to people just, you know, eating better, and that it may reconsider the decision in the future. But obviously cost is a huge issue here. These drugs are less expensive than they were, but they are still super expensive if they’re going to be taken by the millions of people who would qualify for an indefinite period of time. Is there any talk of finding a way to bring that cost down? That would obviously be popular and something that President Trump has said he wants to do in terms of drug prices overall. 

Raman: I have not heard of anything on bringing the cost down. I think that the only discussions that really come about are really tailoring who would qualify within that bucket, and to narrow that as a piece to bring the cost down rather than the cost of the specific drugs. And we’ve been — yeah. 

Rovner: I would say, I know that Ozempic is on the list of Medicare drugs to be negotiated this year, but I think that’s only for the diabetic indication. So on the one hand, that could bring down the cost for— 

Ollstein: And that wouldn’t help people for years and years. Yeah. 

Rovner: Exactly. So I mean we might — if you have diabetes, Medicare could start saving money on one of the GLP drugs, but I guess it’s going to be a while before we see the cost fall. And of course, we didn’t even talk about the potential tariffs on prescription drugs, because we’re not going to talk about that this week. 

That is this week’s news. Now we will play my interview with law professor Stephen Vladeck, then we will come back and do our extra credits. 

I am so pleased to welcome to the podcast Stephen Vladeck, professor at Georgetown University Law School and author of the invaluable Substack “One First,” which helps explain the workings of the Supreme Court to us lay folks. Steve Vladeck, welcome to “What the Health?” 

Stephen Vladeck: Thanks, Julie. Great to be with you. 

Rovner: So I’ve asked you to help us with the next in a series I’m calling “How Things Are Supposed to Work in Health Policy.” And I’m particularly interested in how much power the president has vis-à-vis Congress and the courts. Is there kind of a 30-second law school description of who has the power to do what? 

Vladeck: It’s a little longer than 30 seconds, but to make the long version shorter: Congress makes laws, the president carries those laws into effect, and the courts decide whether everyone’s playing by the rules and abiding by those laws. That’s how it’s supposed to go — and if only that were how it actually was. 

Rovner: Now, I’m not a lawyer, but I have been at this for a long time, and I always understood that executive orders from presidents were mostly for show. They were expressions of intent that needed to be carried out by someone else in the executive branch most of the time, usually using the formal regulatory process. But that is not at all what this administration is doing with its executive orders, right? 

Vladeck: So, Julie, I think part of the problem is that we really are at the apex of something that’s been building for a while, which is that as Congress has stopped doing its job, as Congress has stopped passing statutes to respond to our pressing issues of the day, presidents of both parties have been left to govern more and more aggressively based on increasingly, for lack of a better word, creative interpretations of old statutes and constitutional authorities. And so, yes, I think we’re seeing differences in both degree and kind from President Trump, but some of this has been building for a while where, we haven’t had meaningful immigration reform since 1986. We haven’t had meaningful financial systems reform in 25 years. And so in those spaces, presidents are going to do what they can to try to accomplish their policy goals, which means more and more executive orders where the presidents are at least purporting to interpret authorities that they’ve been given, either by statute or the Constitution, as we get further and further away from those authorities themselves. 

Rovner: So this is the unitary executive theory that we’ve, those of us who play to be lawyers sometimes, have heard about. But how abnormal is what Trump is doing now? Is this even legal, a lot of what he’s doing? 

Vladeck: So a lot of what he’s doing is not legal, but some of it is legal. And one of the complications is that the illegalities are at scales and in ways that we haven’t really seen before and that therefore our existing legal processes aren’t necessarily well set up to respond to. I would break Trump’s behavior into a couple of categories. So I think there’s the internal stuff, which is firing tons of people, hollowing out the bureaucracy, demanding political fealty from even those who are civil servants. And we’ve seen, Julie, I think, flash points of those before. What’s novel about what’s happening now is just the sheer scale on which it’s happening. I think the biggest area of real novel action is the effort by Trump really to sort of change how all federal money is spent, right? Money is supposed to be Congress’s, like, superpower. Not only is appropriations Congress’ most important function, but it’s actually the only thing that the Constitution specifically says only Congress can do. 

And yet we’re seeing really novel assertions by the president of the power to not spend money Congress has appropriated, of the power to stop paying for contracts where the work has already been performed, of the power to threaten Maine and other jurisdictions with the withholding of federal funds if they don’t just bend the knee to Trump. And that is really, I think, both shocking and dangerous because it basically means that the president’s trying to seize unilateral control over what has historically been Congress’ principal vehicle for doing policy. And at that point, you don’t really have much of a separation of powers anymore. You’ve just got a president. 

Rovner: Could Congress take back this authority if it wanted to? 

Vladeck: Sure. But just before letting folks get too optimistic, one of the problems is that taking back this authority probably means, at the very least, passing new statutes, and Trump’s not going to sign those statutes. So one of the things that has been a fear of separation-of-power scholars for a long time is that when Congress delegates authority to the president, or when Congress acquiesces in the drift of power to the president, it’s actually really hard for Congress to get that power back, because it’s usually going to require veto-proof supermajorities, and really hard to see in our current political climate a veto-proof supermajority agreeing even to the fact that today is Tuesday, let alone that we should take back power from the president. So Congress could do tons of things. The problem is that assuming Congress won’t, we really are left to these series of confrontations between the president and the courts, because the courts are all that’s left. 

Rovner: Which brings me to something that I think most people would think would be not really health-policy-related but really is, which are all these threats against these big law firms. How does that play into this whole thing? 

Vladeck: So I think it’s a big piece of the puzzle because what the threats, I think, are really intended to do is to cow law firms into submission, to try to increase the cost both economically and politically of bringing lawsuits challenging what the federal government’s doing. And Julie, I think that the long-term idea is to chill people from suing the federal government, to chill people from hiring folks who worked in administrations from the wrong party in ways that I think are really disruptive not just to the economics of law firms but to the courts. The courts depend upon a strong, robust, and independent bar that is able to actually move freely when it comes to challenging the government. Courts can’t go out and find cases. Lawyers bring the cases to them. And if the lawyers are for some reason disincentivized from bringing those cases, part of the separation of powers breaks down even further. 

Rovner: Or basically, in this case, I guess they’re promising not to bring cases that the administration doesn’t like. 

Vladeck: Exactly. We should be terrified. No matter what you think of lawyers, no matter what you think of the administration, we should want a world in which there’s no disincentive to challenge what the government’s doing in court. We should want a world, as James Madison put it, where ambition is counteracting ambition, where the branches are pushing up against each other, not where they are stunned into submission. 

Rovner: And finally, you’re an expert in the Supreme Court. Is there any chance that the Supreme Court’s going to rescue us here? 

Vladeck: No, but I think what I would say — to try to both be a little more optimistic and to try to put a little more depth into my one-word answer — it’s not the Supreme Court’s job to rescue us. It’s the Supreme Court’s job to protect the separation of powers. And as you and I are sitting here, we’ve seen a couple of early rulings from the court that have kind of sided with Trump in these sort of very, very fleeting technical emergency postures without actually saying anything about what he’s doing is legal. I have at least a modicum of faith, Julie, that when the courts get to the legality questions, they’re going to find that most of this stuff actually is illegal. 

I think the question is, what happens then? And this is why, although I’m as big a believer in a powerful and independent judiciary as anyone, the courts alone can’t save us, right? What we need is we need the courts backed by Congress, by the people, by our other institutions, universities, law firms. I mean it should be all of the institutions of our civil society, not opposing Trump to oppose Trump but standing up for the notion that our institutions matter and that the way that we can be confident that the government is working the way it’s supposed to is when the institutions are pushing up against each other with all their might and without the fear of what’s going to happen to them if they lose. 

Rovner: I feel like one of the bright spots out of this is that finally the nation is getting the lesson in civics that it’s needed for a while. 

Vladeck: I couldn’t agree more. I think we are seeing the very, very real costs of generations of insufficient civics education, but I also think this opens the door to real conversation about how to fix this. And in the short term, some of it is about stopping a lot of what Trump is doing, and that’s what a lot of these lawsuits are about. When we talk about, Julie, building back institutions, whether it’s in the public health space or more broadly, I hope that we keep having the civics lesson, and I hope that we don’t forget that it’s actually really important to have independent agencies, and it’s important to have a civil service, and it’s important to have institutions that are actually not just subject to the whims of whoever happens to be the current president. And the more that we can build off of that going forward, maybe the more that we can prevent what has happened already over the first 11 weeks of the second Trump administration from becoming a permanent feature of our constitutional system. 

Rovner: Well, we will keep at it. I hope you’ll come back and join us again. 

Vladeck: I’d love to. Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Sandhya, why don’t you go first this week? 

Raman: So my piece for extra credit is from me, on Roll Call. It’s called “In Sweden, a Focus on Smokeless Tobacco,” and it’s the first in my series I’m doing through the Association of Health Care Journalists, where I went to Sweden to learn about smoking cessation and public health between Sweden and what we can learn in the U.S. And the story looks at the different political factions of the Parliament over there and how they found some common ground in areas to become hopefully the first country in Europe below 5% daily smokers, and just what lessons the U.S. can learn as they’re trying to reduce smoking here as well. 

Rovner: So jealous that you got to do this. Alice, why don’t you go next? 

Ollstein: I chose a piece from The Guardian by Carter Sherman [“‘We Are Failing’: Doctors and Students in the US Look to Mexico for Basic Abortion Training”] on an issue that has interested me for a long time, which is how U.S. residents are learning how to provide abortions when their training opportunities have been eliminated in so many states. I’ve been covering those who have been traveling to different U.S. states, but this piece is about a small but growing number who are traveling to Mexico for this training. Mexico, like many countries in Latin America and really around the world over the last few years, has moved in the direction of decriminalizing abortion as the U.S. has moved in the opposite direction and is very eager to help train more people. 

But the article stresses that this is not a solution for everyone in the U.S. who needs this training, because you have to be able to speak fluent Spanish in order to do it. You have to already have some abortion experience, which not every medical resident has. And it’s also expensive. There are fellowships, but the trip and the training and everything costs thousands of dollars. And so I think it’s a very interesting opportunity for some people. And the article also talks about folks who are doing some training in the U.K., as well. And so I wonder if these international opportunities will become more of a piece of the puzzle in the future. 

Rovner: Victoria. 

Knight: OK, my extra credit for this week is an article in Wired called “Dr. Oz Pushed for AI Health Care in First Medicare Agency Town Hall.” So basically this was Dr. [Mehmet] Oz’s first town hall talking to CMS [Centers for Medicare & Medicaid Services] staff, and he talked about a lot of his personal story and not as much of the goals of the agency, seemed to be the vibe of the meeting. But also, interestingly, he talked about using AI avatars instead of actual people. So that’s like people that do simple health diagnoses using AI instead to diagnose people, is kind of what it sounded like. And that’s in part because— 

Rovner: My comment to this story was: Not at all creepy. Sorry. 

Knight: Right. And— 

Rovner: I interrupted you, Victoria. 

Knight: No, no, that’s OK. But he was saying the benefit of this is that it could cost less because it could only cost maybe like $2 an hour versus a doctor could be a hundred dollars for a consult. And so people interviewed in the story were CMS employees that felt very concerned about that and also felt like it could come off a bit tone-deaf when there have been a bunch of CMS staff also just recently let go. And CMS was actually on the agencies that was hit with less workforce cuts. But even so, people are still upset about it. And so, it was like, Why are you replacing great people that worked here with AI? It was just an interesting look at his first week at the agency 

Rovner: Yeah. And it’s a big agency with a lot of money. All right, my extra credit this week is from The New York Times. It’s called “Why the Right Still Embraces Ivermectin,” by Richard Fausset. And it’s a pretty hair-raising story of medical malfeasance, foisted on people by those seeking political or financial gain or both. Quoting from the story: “Ivermectin has become a sort of enduring pharmacological MAGA hat: a symbol of resistance to what some of the movement described as an elitist and corrupt cabal of politicians, scientists and medical experts.” This is another in a long list of unproven remedies people take just to thumb their noses at treatments that have, you know, actual scientific evidence behind them. It’s a really interesting read. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you folks these days? Alice, you’re the birthday girl. Where can we all wish you a happy birthday? 

Ollstein: Mainly on Bluesky, @alicemiranda, but still hanging on X, @AliceOllstein. 

Rovner: Sandhya. 

Raman: On X and Bluesky, @sandhyawrites. 

Rovner: Victoria. 

Knight: I’m just on X, @victoriaregisk. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

The Department of Health and Human Services underwent an unprecedented purge this week, as thousands of employees from the National Institutes of Health, the FDA, the Centers for Disease Control and Prevention, and other agencies across the department were fired, placed on administrative leave, or offered transfers to far-flung Indian Health Service facilities in such places as New Mexico, Montana, and Alaska. Altogether, the layoffs mean the federal government, in a single day, shed hundreds if not thousands of years of health and science expertise.

Meanwhile, the Supreme Court heard a case about whether states can bar Planned Parenthood from providing non-abortion-related services to Medicaid patients. But by the time the case is settled, it’s unclear how much of Medicaid or the Title X Family Planning Program will remain intact.

 This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs Zhang of Bloomberg News, Sarah Karlin-Smith of the Pink Sheet, and Lauren Weber of The Washington Post.

Panelists

Rachel Cohrs Zhang
Bloomberg News

@rachelcohrs

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Lauren Weber
The Washington Post

@LaurenWeberHP

Read Lauren's stories.

Among the takeaways from this week’s episode:

• As details trickle out about the major staffing purge underway at HHS, long-serving and high-ranking health officials are among those who have been shown the door: in particular, senior scientists at FDA, including the top vaccine regulator, and even the head veterinarian working on bird flu response.
• The Trump administration has also gutted entire offices, including the FDA’s tobacco division — even though the division’s elimination would not save taxpayer money because it’s not funded by taxpayers. Still, the tobacco industry stands to benefit from less regulatory oversight. Many health agencies have their own examples of federal jobs cut under the auspices of saving taxpayer money when the true effect will be undermining federal health work.
• Democratic Sen. Cory Booker of New Jersey set a record this week during a marathon, 25-hour-plus chamber floor speech railing against Trump administration actions, and he used much of his time discussing the risks posed to Americans’ health care. With Republicans considering deep cuts that could hit Medicaid hard, it’s possible that health changes could be the area that resonates most with Americans and garner key support for Democrats come midterm elections.
• And the tariffs unveiled by President Donald Trump this week reportedly touch at least some pharmaceuticals, leaving the drug industry scrambling to sort out the impact. It seems likely tariffs would raise the prices Americans pay for drugs, as tariffs are expected to do for other consumer products — leaving it unclear how Americans stand to benefit from the president’s decision to upend global trade.

Also this week, Rovner interviews KFF Health News’ Julie Appleby, whose latest “Bill of the Month” feature is about a short-term health plan and a very expensive colonoscopy. Do you have a baffling, confusing, or outrageous medical bill to share with us? You can do that here.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Stat’s “Uber for Nursing Is Here — And It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda.

Sarah Karlin-Smith: MSNBC’s “Florida Considers Easing Child Labor Laws After Pushing Out Immigrants,” by Ja’han Jones.

Lauren Weber: The Atlantic’s “Miscarriage and Motherhood,” by Ashley Parker.

Rachel Cohrs Zhang: The Wall Street Journal’s “FDA Punts on Major Covid-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White.

Also mentioned in this week’s podcast:

• Stat’s “Laid-Off HHS Leaders Offered Transfers to Remote Indian Health Service Regions,” by Usha Lee McFarling.
• The Washington Post’s “Fired Health Workers Were Told To Contact an Employee. She’s Dead.” By Lauren Weber.
• Georgia Recorder’s “Bill That Criminalizes Abortion, Undermines IVF Access Gets Georgia House Panel Hearing,” by Jill Nolin.

Click to open the transcript

Transcript: American Health Gets a Pink Slip

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, April 3, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, Julie. 

Rovner: Lauren Weber of The Washington Post. 

Lauren Weber: Hello hello. 

Rovner: And we welcome back to the podcast Rachel Cohrs Zhang, now at Bloomberg News. 

Rachel Cohrs Zhang: Hi, everyone. 

Rovner: Later in this episode we’ll have my interview with my colleague Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month,” about yet another very expensive colonoscopy. But first, this week’s news. 

We’re going to start this week, as usual, with the latest changes to the Department of Health and Human Services from the Trump administration. But before we dive in, I want to exercise my host prerogative to make a personal observation for those who think that what’s happening here is, quote, “politics as usual.” I am now a month into my 40th year of covering health policy in Washington and HHS in particular. When I began, Ronald Reagan was still president. So I’ve been through Democratic and Republican administrations, and Democratic- and Republican-controlled Congresses, and all the changeovers that have resulted therefrom. 

And obviously the HHS I cover today is far different from the one I covered in 1986, but I can safely say I have never seen such a swift and sweeping dismantling of the structure that oversees the U.S. health system as we’ve witnessed these past 60 days. Agencies and programs that were the result of years of expert consultations and political compromises have been summarily eliminated, and health and science professionals with thousands of years of combined experience cut loose via middle-of-the-night form emails. To call the scope and speed of the changes breathtaking is an understatement, and while I won’t take any more personal time here, if you want to hear me expand further on just how different this all really is, I’m on this week’s episode of my friend Dan Gorenstein’s “Tradeoffs” podcast, which you should all be listening to anyway. 

All right. That said, now let’s dive in. I suppose it was inevitable that we would see the results of last week’s announced reorganization of HHS on April Fools’ Day. Let’s start with who was let go. While the announcement last week suggested it would mostly be redundancies and things like IT and HR and procurement, there were a bunch of longtime leaders included in this purge, right? 

Karlin-Smith: Yeah. At FDA [the Food and Drug Administration] there were some of the most senior scientists, like their Office of New Drugs directors, their chief medical officer, almost everybody who works on policy, legislative affairs, entire communications offices, external affairs. And even in the case where they are laying off people whose job titles might sound extraneous, or not as important to the health of people in the U.S., I think you can sort of debate that, but they did it in such a way that they laid off so many people in those departments that the people they said, We are protecting, because we do at least understand these jobs are important, cannot actually fully do their jobs. So scientists are not able to access the supplies they need. It’s not even clear how people at FDA are going to get paid and do their timesheets and track time given how many people they laid off. 

And it also just seems like there’s been a ton of, again, to the extent they were trying to protect certain positions that they deemed more critical to U.S. health and well-being, like medical reviewers or inspectors, they didn’t quite understand who actually is critical to doing that work, because it’s not just somebody who has, like, “inspector” in the title. Vanity Fair had a great piece about this man who really has saved people in the U.S. from going blind by helping inspectors catch sterility issues in eye drops, and they walk through very clearly how people like him do not have a title of inspector but are absolutely needed to ensure we have drugs that are safe for people in the U.S. So, probably not surprising to people who’ve tracked the administration so far, but it’s been a lot of the move-fast -break-things, and then realize on the back end that they maybe broke things they didn’t necessarily mean to, or don’t actually care as much about whether it’s broken. 

Rovner: Lauren. 

Weber: They got rid of the head veterinarian on the bird flu response. That would seem to be a thing that is surprising. I spoke to a congressman yesterday who said that seems very dumb. It’s not just that. They also eliminated entire swaths of the CDC [Centers for Disease Control and Prevention], small agencies that maybe a lot of people have no idea alphabetically what they do but are pivotal in preventing injury deaths, and in really the preventative and chronic disease care that RFK [Robert F. Kennedy Jr.] has said is really vital to getting America back on track. When we talk about dollars and cents saved in health care, a lot of that is in chronic disease and in preventative care. And to see some of these places get hit so broadly is quite shocking considering the end goal is allegedly to save money. 

Rovner: There are also a lot of things that seem sort of at odds with [President Donald] Trump’s own agenda. David Kessler, the former FDA commissioner, was on TV last night talking about how the people who answer the phones when a doctor wants to get an emergency use authorization for a drug that’s not yet approved. That’s something that’s been a very big deal for Donald Trump. The people who answer the phones got fired. So, when a doctor has a patient who, nothing else will work and they need an experimental drug, and they’re supposed to be able to call FDA. And I think there are rules about how fast FDA is supposed to respond. But now there’s nobody to actually answer the phone and take those requests. 

Karlin-Smith: Yeah, I think the list of things that don’t seem to align is very long. One thing I was talking to somebody about yesterday who said, well, pretty much everybody who deals with tracking pesticides in foods, and food safety at the FDA in regards to pesticides was let go. And making our food system healthier and safer, and concerns about pesticides, has actually been a big focus of RFK. Similarly, Martin Makary talked a lot in his opening speech to FDA employees yesterday about obesity, and they are basically gutting offices that work on pediatrics, minority health. They’ve laid off lots of people in their tobacco division at FDA, and FDA’s tobacco division actually is not funded at all by taxpayer funding. So, I have a hard time understanding how anybody besides the tobacco industry really benefits from this loss. As Lauren said, it’s like every health agency, you can kind of find examples of that. They say America is not healthy, but they’re cutting these top researchers that have found incredible advances in Parkinson’s and some of the chronic diseases he’s most cared about. 

Rovner: They also, I mean, there are some big names who were let go. We didn’t even — the Peter Marks firing at FDA happened last week after we taped, so we haven’t even talked about that. Somebody tell us who Peter Marks is and why everybody’s all freaked out about that. 

Cohrs Zhang: Well, Peter Marks was head of the division of biologics and the top regulator of vaccines, and complicated injectable medicines like insulin products, too, fell under his purview. And I think we saw markets react in a panic on Monday. The shares of vaccine makers like Moderna were falling. And we saw companies selling gene therapies that Peter Marks has been really involved in regulating and championing through some of those processes, they were kind of freaked out because it just creates uncertainty as to kind of what the new philosophy toward these medicines will be. And the Trump administration, we’ve seen, especially on the Marks being pushed out, I think they’ve tried to highlight some of his more controversial actions in the past. 

We saw a White House adviser, Calley Means, was personally attacking Marks for some conflicts he had with vaccine regulators during debate over the covid booster approvals, and just his decisions to overrule recommendations by FDA experts on some innovative medications that some people disagreed with. But the perspective from former officials has been that, like Peter Marks or not, the idea that scientific expertise is being purged in this way is concerning. And it wasn’t just Peter Marks. There’s another regulator at the Office of New Drugs, Peter Stein. who was pushed out. We have Anthony Fauci’s successor at NIH [the National Institutes of Health] was pushed out, Jeanne Marrazzo, as well as a couple other heads of scientific research institutes at NIH. 

Rovner: Anthony Fauci’s wife was pushed out— 

Cohrs Zhang: Yeah. Yeah. 

Rovner: —as the head of the office of bioethics at NIH. 

Cohrs Zhang: Truly, and I think we had heard that some of these more politically sensitive center leader positions would be at risk. We’ve heard this for a very long time, but it seems like they took advantage of the chaos to implement some of these high-level cuts to people that they may have disagreed with. But, like, people will be filling those positions. I don’t know that there’s a cost-saving argument there. But it certainly seems like they were trying to push out senior leaders with a lot of experience. 

Rovner: It also feels like, the way that people were let go seems, to put it bluntly, purposely cruel, like sending out RIF [reduction in force] notices at 5 a.m. and then having people find out they’ve been let go when they stand in long lines only to find out that their IDs no longer work, or CMS [Centers for Medicare & Medicaid Services] employees being directed to contact a person who died last year. Is there a strategy here? Lauren, you wanted to add something. 

Weber: I wrote a story on the CMS employees being told to contact someone who was dead. And I spoke to one of this woman Anita Pinder’s former colleagues who said she was just heartbroken. She said CMS employees who got that email had gone to this woman’s funeral, and what a gut punch. She said, Look — this person who was talking to me is a former CMS employee — said: Look, you know, there always is a way to reorganize. It’s not that there isn’t waste or ability to consolidate or streamline in the federal government. She’s like, That’s not my problem. My problem, this woman told me, was that it was done in such a way that you really can’t take that back. People getting a dead woman’s name as their point of contact to contest their firings is something that is difficult to take back. 

Rovner: I guess my question is: Is this just sloppy, or are they actually trying to be cruel in this? Because it certainly feels like they’re trying to be cruel. 

Karlin-Smith: I think it’s possible. It’s both, a combination, one or the other. Again, it seems like the people who are doing this are not expert, right? They didn’t actually take the time to assess HHS and all what the agency does to understand what people do for the government beyond just looking at their job titles. And so some of it may be intentional cruelty, and some of it just may be really just rushing and not understanding the process. I mean, there were other notices at FDA that were signed by somebody that no longer worked there. People’s performance scores were wrong. The sense is they didn’t follow the normal process of, like, when you do a RIF, you have to give — there’s certain people that get preferences and who stays and who goes and whether it’s veteran status, disability, all those things. 

And I think some of that will probably result in legal challenges down the line, including they got rid of certain offices, or everybody in them, that were mandated by Congress. So some of it’s probably sloppy, but some of it is — right? — they don’t really care how they treat people, because there is like a very clear message that comes from their rhetoric of kind of lack of respect for government bureaucracy. 

Rovner: And I know some of these senior leaders, they figured out that they can’t just summarily fire them. So a number of them were offered transfers to the Indian Health Service in places like Alaska and Montana, and they were given 36 hours to decide whether they would accept the transfer. And we are told that Secretary Kennedy is very concerned about Native populations and the Indian Health Service, which is short of workers in a lot of places. But this seemed to be insulting to both the people who were given these quote-unquote “transfers” and to the Indian Health Service, because it wasn’t sending the Indian Health Service what it actually needs, which are practitioners, doctors and nurses, and laboratory workers. It was sending research analysts and bench scientists and people whose qualifications do not match what the IHS needs. 

Karlin-Smith: Right. They wanted to send, I think, the FDA’s tobacco head to the IHS to do, I think, medical care. So it enraged people in the IHS. 

Rovner: Yeah, I don’t think the Native population was really thrilled about this, either. Lauren, you wanted to add something. 

Weber: Yeah, I would just say that this is a playbook the Trump administration has executed in other government agencies. Members of the FBI, top leaders of the FBI were reassigned to child sex trafficking crimes or faraway distant lands in the hopes of getting them to resign. So, I think we are seeing that play out at HHS, but it certainly is a tactic they’ve used in other federal agencies to, quote-unquote, “drain the swamp.” 

Rovner: Right. And in the first Trump administration, they did move some offices out of Washington to the middle of the country, if you will, and most people obviously didn’t go. And now there’s a lot of expertise that, again, that we lost. I think that really can’t be overstated, is how much expertise is being pushed out the door right now, in terms of things that, as I said, this administration says that it wants to do or get accomplished. Meanwhile, Secretary Kennedy has been invited — or should I say summoned — to come testify next week before the Senate health committee at the behest of Republican Chairman Bill Cassidy, Democratic ranking member Bernie Sanders. So far Congress has mostly just been kind of sitting back and watching all of this happen. Is there any indication that that’s about to change? 

Karlin-Smith: I think Democrats are pushing a little bit harder, but I’m not sure they have enough power or have enough, again, momentum yet to actually do what they can with their power. I’m interested to see how Cassidy handles this hearing going forward because his statement the day of the big reduction in force seemed to suggest that the media was maybe unfairly reporting on it and that Kennedy may have another side to the story to share to justify it. And it didn’t sound like somebody that was necessarily going to go particularly hard at RFK. It seemed like somebody who wanted to give him a chance to justify his moves. But we’ll see what happens. I think Cassidy has been, despite RFK walking back a lot of his promises he made to Cassidy around vaccines and so forth, Cassidy has not been that willing to go hard on him so far. 

Rovner: Yeah, the other thing we’ve seen is that most of the big health groups that you would expect to be out on the front lines, hair on fire, have actually been keeping their heads down through most of these huge changes. But that seems to be maybe changing a little bit, too. This is a pretty dramatic change to get not a huge response from. I’ve seen way lesser changes get way bigger responses. 

Cohrs Zhang: Yeah, I think I spend a lot of time thinking about what is going to be the last straw for some of these organizations. And I think we saw some more effective organizing from the, like, medical device industry when actual medical device reviewers were laid off, and I think they went public pretty quickly, and those people were rehired. But I think it’s important to remember that some of these larger trade organizations in these companies are looking at a broader picture here. And there are all these different pieces of the puzzle. And certainly I think we’ve seen some trade groups that represent, like, pharmaceutical companies criticize some of the cutbacks at HHS, but also for now they were spared in a tariff announcement this week. 

And so I think they are trying to walk this tightrope where they have to figure out how to get the wins that they think they need and take losses in other place, and hope it kind of all evens out for them. So, I think they’re in a tough situation, and I think there’s much more concern behind the scenes than we’re seeing spill out into the public. But I think at some point maybe the line will be crossed, and I just don’t think we’ve seen that quite yet. 

Karlin-Smith: Yeah, I think the dam is definitely starting to break a bit, though. I was shocked — I guess, what day was it, Tuesday, when all this happened? — when finally late in the day, pharma sent a statement, and it was more scathing than you might even expect. And I think it was the first time they’ve actually responded to anything I’ve asked them to respond to that the administration does. And they said that it’s going to raise crucial questions about the FDA’s ability to fulfill its role. And so I think that is a big sign because, as Rachel mentioned, the medical device community was willing to stick their neck out there when they felt they were really harmed. Smaller trade associations have been starting to push back, but the silence has really been notable, and notable I think by people outside who were hoping that these powerful industries that have sort of more connections to the Republican Party would use that leverage, and they sort of felt abandoned by them. So, I think that is a significant crack to follow. 

Rovner: I feel like everybody’s waiting for somebody else to stand up and see if they get their head chopped off. I agree. I mean, I’m hearing, quietly, I’m hearing the concern, too, but publicly not so much. Well, moving to Capitol Hill, Congress is in this week. Well, they were in. We’ll get to the House in a minute. But first in the Senate, New Jersey’s Cory Booker set a new record for holding the floor, which is saying something for a place where being long-winded is basically a prerequisite. Twenty-five hours and five minutes, besting by almost an hour the 1957 filibuster against the Civil Rights Act by Strom Thurmond of South Carolina. Much of what Booker talked about during his more than a day on the Senate floor was health care. Is this still the issue that Democrats are hoping to ride to their political return? 

Weber: I was going to say, if the massive Medicaid cuts that are forecast come through, I do think that will be the midterm political return of Democrats. I think the writing is on the wall politically for Republicans if those do go through, which is why I think you’re seeing a lot of Republican leaders start to say: Oh, no. No, no, no. We don’t want some of these Medicaid cuts like this. But to be determined how that actually plays out. 

Rovner: Rachel. 

Cohrs Zhang: I was just going to say that Democrats are just trying to figure out something that will break through to people. They’re just trying to throw spaghetti at the wall and see if there’s some strategy they can find to get through to people. And I think this, just given the viewership of Sen. Booker’s speech, seemed to break through in a way and felt like even though Democrats do have really limited levers of power in Washington right now, that at least somebody was doing something, you know. And that’s kind of the takeaway that I had from that speech. 

But I will say I think Congressman Jake Auchincloss appeared after White House adviser Calley Means criticized the scientific establishment and HHS and was defending these cuts, and Congressman Auchincloss, I think, did have a more forceful tone in pushing back and just arguing for the scientific advances that have happened and had some really camera-ready little tidbits about the new administration being run by like conspiracy theorists and podcast bros. And I think they’re trying to figure out how to push back and how to get through to people and what approaches are going to work. And I think that was just a new tactic that we saw break through. 

Rovner: Well, if the Democrats did want to make a statement about Medicaid, they could make a stand against President Trump’s nominee to head the Medicaid program, as well as Medicare and the ACA [Affordable Care Act], Dr. Mehmet Oz. That vote is scheduled in the Senate for today after we finish taping. But we’re not really seeing that much pushback. Are we, Lauren? 

Weber: Not so far. I guess we’ll see. We’re taping before this happens. But Mehmet Oz really waltzed through his confirmation hearing process. It’s rare that you see someone who will lead such a massive agency on health care mention the multiple Daytime Emmys he’s won, but I think that helped in his charming of legislators. His daytime bona fides were on high display. He was able to dodge multiple questions about what he would do about cuts to Medicaid, and even Democratic senators were inviting him to come to church. I would be surprised if we see some sort of big stand today. 

Rovner: He was super well prepped, which we said — we did a special after the hearing — which is of all of the Trump nominees, I think he was the best prepped of anybody I’ve seen. He was ready with tidbits from every single member of the committee. But I will say that, going back years, and as I said, you know, 40 years, this is a position that one party or the other has frequently blocked, not for reasons that the nominee was not qualified but because they wanted to make a point about something that was going on at the agency. And it kind of surprises me that we haven’t seen that sort of thing. There were years where we did not have a Senate-approved head of Medicare and Medicaid. Sarah, as you pointed out, there were years when we didn’t have a Senate-approved head of the FDA for the same reason. Had nothing to do with the nominee. Had everything to do with the party that was out of power trying to use that as leverage to make a point. And we’re just not even seeing the Democrats try that. 

Weber: I guess we’ll see this afternoon. You could be forecasting what’s going to happen, Julie. But I think on top of him being well prepped, Oz does have a history in health care, is a very accomplished surgeon. But what is fascinating to me is that he’s coming back to the Senate after a 2014 grilling by the Senate on his pushing of supplements and other things for, quote, “fat blasting” and, quote, “weight loss” products. And it’s just the turnaround of daytime TV star to failed Senate candidate to potential administrator for CMS, which runs hundreds of millions Americans’ health insurance, potentially at a very consequential period in which there are massive cuts to them, is really going to be something. 

Rovner: Yes. Yet another eye-opening thing out of this administration. Well, over in the House, things are a little more confusing. On Tuesday, the usually unified Republicans rejected a rule, normally a party-line , because Speaker Mike Johnson was using it to avoid a vote on a bill that would allow new parents to vote by proxy, basically granting them parental leave. I did not have this fight on my bingo card for this year. It’s actually less a partisan fight than one between younger — read, childbearing age — members of Congress and older ones from both parties. I’m kind of surprised that this of all things is what stopped the House from doing business this week. 

Cohrs Zhang: Yeah, I think that it is an interesting contrast here because House Republicans have had this very pro-family rhetoric in the campaign, but they also have been so against remote work in any fashion, and members of Congress travel really far. There’s a time in pregnancy when you can no longer fly on a plane. And so I think given Republicans’ really, really slim majority in the House, it puts them in kind of a pickle where they need these votes to keep the majority, but it kind of sits at the intersection of all these different forces at play. So, I think, yeah, just a really weird political pickle that House Republicans have found themselves in this week. 

Rovner: Yeah, and of course this was a member of the House Freedom Caucus, a Republican member of the House Freedom Caucus, who was pushing this, who got a majority of the House to sign her discharge petition, which is supposed to bring this bill to the floor. So, we will see how that one plays out. Obviously, with everything else that’s going on, it’s not the biggest story, but it sure is interesting. 

Well, the big non-health news of the week are the tariffs that President Trump announced in the Rose Garden Wednesday afternoon. There is a health care angle to this story. The tariffs reportedly include at least some drugs and drug ingredients that are manufactured overseas. This, again, feels like it’s going to do exactly the opposite of what the president says he wants to do in terms of reducing drug prices, right? 

Weber: I mean, yes, yes. That would seem to be exactly how that is likely to go. Even look at drugs we get from Canada. They’re going to have tariffs on them. I think we have to wait and see exactly what happens. Trump has had a history of proposing these and then taking them back. Obviously these are much more sweeping than the ones we’ve seen so far. So, I think it, the jury is out on how exactly this will play out over the next couple weeks. 

Rovner: Right. And I said there’s also the exception process, right? 

Karlin-Smith: So, yeah, there’s been I think a lot of confusion and lack of clarity around exactly what happened yesterday here. It seems like the drug industry did get some key exemptions, but people are trying to kind of clarify some of those, including, like: Do you just apply to finished product? Do ingredients that they need lower down in the supply chain get impacted? So, I think it seems like pharma at least got some amount of a win here and got some of the typical exemptions for medicines, but people are not confident in all of that and how it’s going to play out. And I’ve seen sort of mixed reactions from analysts in the space. But yeah, it’s just like other parts of the economy that people have talked about with tariffs. It’s not entirely clear how the average American consumer would actually benefit from these tariffs versus having to just pay more money for goods. 

Rovner: We are apparently going to tariff penguins from islands off the coast of Australia. That much we seem clear on this morning. Turning to abortion, this week, as we mentioned last week, the Supreme Court heard a case out of South Carolina testing whether a state can kick Planned Parenthood not just out of the federal Family Planning Program, Title X, but whether Planned Parenthood can be disallowed from providing Medicaid services as well. Now, Planned Parenthood gets way more money from Medicaid than it does from Title X, and neither program allows the use of federal funds to pay for abortion. I will say that again: Neither program allows the use of federal funds to pay for abortion. Interestingly, it seems the high court might actually be leaning towards Planned Parenthood in this case, not because the conservative justices have any sympathy towards Planned Parenthood but because the court has fairly recently made it clear that the provision of Medicaid law that says patients can choose any qualified provider actually means what it says: The patient can choose any qualified provider. 

At the same time, though, the Trump administration this week declined to distribute a big swath of that Title X funding. And you have to wonder whether, even if Planned Parenthood wins this South Carolina case, what’s going to be left of either Title X or the Medicaid program. Possibly a Pyrrhic victory coming here? It seems that this administration is just whacking things, and even if the court ultimately says you can’t kick them out, there’s going to be nothing for them to stay in. 

Karlin-Smith: Well, the any-willing-provider debate struck me as sort of most interesting here because that type of clause seems to be something you typically see conservatives want to put into a government health program. They don’t feel comfortable kind of restricting people and choices in that way around who they see. So that was one of the elements of this case. The other thing that I think is being watched is this argument that the state is making around, like, how you enforce disagreements, I guess, around how the Medicaid program is being operated. And that seems like it could have a lot of long-lasting impacts as well if people, depending on if the court weighs in on that and so forth, just what rights people have to contest problematic decisions made in state Medicaid programs. 

Rovner: Yeah, for the first hour of the debate, the word “abortion” wasn’t mentioned. The word “Planned Parenthood” wasn’t mentioned. This was really about whether patients actually have a right to sue over not being able to get the kind of care that they want, which has been a long-standing fight in Medicaid, back to, I think, pretty much the beginning of Medicaid. So, we’ll see how this one comes out. Well, turning to the states and another case we have talked about, Texas wants to prosecute a New York doctor who was acting legally under New York law from prescribing abortion pills via telemedicine to a Texas patient. The latest is that the court clerk in Ulster County, New York, has refused to file a judgment for the $100,000 fine that Texas says the New York doctor owes. 

At the other end of the spectrum, in Georgia, meanwhile, lawmakers held a hearing on a bill that would — and I’m quoting from a Georgia state news service here — “ban abortions in Georgia from the moment of fertilization and codify it as a felony homicide crime unless a pregnant woman was threatened with violence to have the procedure.” Now, under this bill, both the woman and the doctor could be charged with murder. This bill is unlikely to be enacted this year, but I feel like the Overton window on this continues to move towards maybe punishing women with poor pregnancy outcomes. 

Karlin-Smith: Well, and punishing women who have trouble getting pregnant, as some of the opponents of this bill are arguing. It’s not clear whether it will really be possible to do IVF procedures if the bill was enacted how it was written. And even it seems like some of the reason why some pretty anti-abortion groups are concerned about this law, because they feel uncomfortable that it’s penalizing or going after the woman rather than other people involved in the abortion system. 

Rovner: I feel like we’ve been creeping this direction for a while, though. Obviously, this bill’s probably not going to move this cycle, but it got a hearing. We’ve seen a lot of things like this introduced. We’ve rarely seen it progress to the hearing stage. Another thing that bears watching. So, last week in the segment that I’m now calling “MAHA [Make America Healthy Again] in the States,” we talked about West Virginia banning food dyes and additives. Well, hold my beer — um, make that water, says Utah. Utah has now become the first state to ban fluoride in public water systems, something takes effect next month. Lauren, I feel like states are rushing to match RFK Jr. Is that what we’re seeing? 

Weber: There is some interest at the state level, but I also think it speaks to RFK’s limitations. I think everybody always thinks the game is always in D.C., but there’s a lot the states can do. And so I think it’ll be fascinating to kind of see how this continues to play out. 

Rovner: Yeah, well, we will keep watching it. All right, that is this week’s health news. Now we will play my interview with KFF Health News’ Julie Appleby. Then we will come back and do our extra credits. 

I am pleased to welcome back to the podcast KFF Health News’ other Julie, Julie Appleby, who reported and wrote the latest KFF Health News “Bill of the Month.” Julie, welcome back. 

Julie Appleby: Thanks for having me. 

Rovner: So, this month’s patient is yet another with a gigantic colonoscopy bill, but there’s a twist with this one. Tell us who he is and, important for this story, what kind of health insurance he has. 

Appleby: Yes, absolutely. His name is Tim Winard, and he lives in Addison, Illinois. He bought his own health insurance after he left his management job to launch his own business. So he shopped around a little bit. This is the first time he’s bought insurance. And he chose a short-term policy, which is good for six months in his state. And the first six months went pretty well. And he was still working on starting his business, so he signed up for another short-term policy with a different insurer. And this one cost about $500 a month. 

Rovner: So, remind us again. What is short-term health insurance? And how is it different from most employer and Affordable Care Act coverage? 

Appleby: Right. These types of policies have been sold for years. They’re generally intended for people who are, like, between jobs or maybe just getting out of school. They’re a temporary bridge to more comprehensive insurance, and as such they are not considered Affordable Care Act-qualified plans. So they don’t have to meet the rules that are set under the Affordable Care Act. So, for example, they might look like comprehensive major medical policies, but they all have sort of significant caveats. And some of these might surprise people who are accustomed to work-based or ACA plans. So, for example, like in Tim Winard’s plan, some set specific dollar caps on certain types of medical care, and sometimes those are, like, per day or per visit or something like that, and they can be sometimes far below what it actually costs. 

And all of them — this is a key difference with ACA plans — all of these types of short-term plans screen applicants for health conditions, and they can reject people because of health problems or exclude those conditions from coverage. Many also do not cover drugs or maternity care. So people really have to read their policies carefully to see what they cover and what they don’t cover. 

Rovner: So this is sort of like pre-ACA. It’s cheap because it doesn’t cover that much. 

Appleby: Exactly. That’s why they can offer them lower premiums. Now, again, some people with a subsidized ACA plan, these are not necessarily cheaper, but for others these are less expensive. 

Rovner: So back to our patient this month. He does what we always advise and calls his insurance company before he goes for this, because it is obviously scheduled care, not an emergency. What did they tell him? 

Appleby: Well, I think he only asked where he could go. He was concerned that he would go to a facility that was in-network, and they told him he could pretty much go anywhere. He did not ask about cost in that phone call. 

Rovner: Yeah, so he gets his colonoscopy. Everything turns out OK medically. And then, as we say, the bill comes. How big was it? 

Appleby: He was left owing $7,226 after his plan paid about $817 towards the bill. They got a little bit of a discount for being insured, but then he was still left owing more than $7,000. 

Rovner: And what was the explanation for him owing that much? Just a reminder that this should have been fully covered if he’d had an ACA plan, right? 

Appleby: That’s correct. Under the ACA, screening colonoscopies and other types of cancer screenings are covered without a copay for the patient. But he didn’t have an ACA plan here. So, what was the explanation? Well, this time he did email his insurance company, which is Companion Life Insurance of Columbia, South Carolina, and they wrote him back, and they told him his policy classified the procedure and all of its costs, including the anesthesia, under his policy’s outpatient surgery facility benefit. What is that? you might ask. Well, in his policy, that benefit caps insurance payments within that facility to a maximum of a thousand dollars per day. So, the most they were going to pay towards this was a thousand dollars, because they classified the whole thing as an outpatient procedure with that cap. And this surprised Winard because he thought the cancer screening was covered and he would only owe 20% of the bill, not almost the entire thing, basically. 

Rovner: So how did this eventually work out? 

Appleby: Well, we reached out and tried to reach Companion Life, and we also talked to Scott Wood, who works as a program manager and is a co-founder of a marketing company that markets Companion Life and other insurance plans. And he thought there was some room for interpretation in the billing and in the policy language. So he asked Companion Life to take another look. And shortly after that, Winard said he was contacted by his insurer, and a representative told him that upon reconsideration the bill had been adjusted. And he wasn’t really given a reason why that happened, but as it turns out his new bill showed he owed only $770. 

Rovner: Which is, I assume, about what he expected when he went into this, right? 

Appleby: That’s, yes, correct. He didn’t think he was going to have to pay as much as it was initially billed at. 

Rovner: So, what’s the takeaway here other than to come to us if you have a bill that you can’t deal with? 

Appleby: Right. Well, I think experts say to be very cautious and read the plans very carefully if you’re shopping for a short-term plan. And realize they have some of these limits and they may not cover everything. They may not cover preexisting conditions. And this could become more widespread in the coming years as — short-term plans have been somewhat of a political football. So, out of concern that people would choose them over more comprehensive coverage, President Barack Obama’s administration limited them to terms of three months. Those rules were lifted during the first Trump administration, and he allowed the plans to again be sold as 364-day policies, just one day short of a year, and then you could try to get another one. Or in some cases the insurer could opt to renew them. 

And then Joe Biden came in, and President Biden called them “junk insurance,” and he restricted the policies to four months. So, it’s been bouncing back and forth, back and forth. Everybody really expects the Trump administration to do what it did the last time and make them available for longer periods. So I think if we’re going to hear more about short-term plans. They may become more common. And again, it’s just a matter of trying to understand what you’re buying, and why they might be less expensive in your mind than an ACA plan, but they might not turn out to be. 

Rovner: And you can always ask for an estimate, right? 

Appleby: And always ask for an estimate. That’s a given. Experts always say, before any kind of scheduled procedure, call your insurer, call the provider, ask for an estimate on how much this might cost you out-of-pocket. 

Rovner: Good. And if all else fails, then you can write to us. 

Appleby: There you go. 

Rovner: Julie Appleby, thank you very much. 

Appleby: Thanks for having me. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Rachel, why don’t you go first this week? 

Cohrs Zhang: All right. My extra credit is a piece in The Wall Street Journal, and the headline is “FDA Punts on Major COVID-19 Vaccine Decision After Ouster of Top Official,” by Liz Essley White. It’s a great story, and I think, as we talked about earlier, I’m thinking about: What are the breaking points for companies, for industries, as they look at how the HHS is changing? And I think one of those metrics is if the FDA starts missing deadlines to approve products. I think this one is a little bit of a special case because it is a covid-19 vaccine, which is, like, the most highly politicized medical product right now. But I think there could be other cases, and I think industry is watching this so closely to see if some of these changes at FDA really do bleed into approvals, whether the approval process will be politicized, whether they’re going to start missing deadlines. And given just the amount of financial support that industry provides to fund routine activities, I think this was kind of a really good marker in this process as we learn what the impacts are. 

Rovner: Yeah, agree. Lauren. 

Weber: I read “Miscarriage and Motherhood” by Ashley Parker, now at The Atlantic. And I’ve got to be honest — if you read it, be in a place where you can cry. It’s an incredibly moving piece about tragedies of miscarriage, and frankly about women’s health care, and how little support and understanding there is in general about what surrounds that entire field. And some of the fascinating parts in it is when Ashley details going in for a D&C [dilation and curettage] and being told that is an abortion. And it’s kind of an interesting interplay between how what words mean, what people understand what words mean, and what exactly parenthood entails in modern America today. 

Rovner: And how extremely common miscarriage is. I think people just don’t realize, because it’s something that’s just not talked about very much. It’s a really beautiful story. Sarah. 

Karlin-Smith: I looked at an MSNBC piece [“Florida Considers Easing Child Labor Laws After Pushing Out Immigrants”] by Ja’han Jones, about Florida considering easing their child labor laws after pushing out immigrants. And, yeah, the state is considering bills that would allow very young teenagers to work overnight, to maybe work at the kinds of jobs that would normally be seen as too unsafe for such young people. And, yeah, it just seems like an interesting sort of consequence of pushing out immigrant workers. But also it comes after some really moving reports over the past few years, too, about just how dangerous some of this work is, and how even under current law that is supposed to prevent this, particularly immigrants and the most vulnerable workers have ended up with young people in this job, and they’ve really — these types of jobs — and they’ve been harmed by it. 

Rovner: Who could have possibly seen this coming? Sorry. My extra credit this week is from Stat, and it’s called “Uber for Nursing is Here — and It’s Not Good for Patients or Nurses,” by Katie J. Wells and Funda Ustek Spilda. And it’s yet another case of something that sounds really good, using an app to help nurses who want to find extra work and set their own schedules get it, and helping facilities that need extra help find workers. But like so many of these things, it’s not as rosy as it appears unless you’re the one that’s collecting the fees from the app. Workers are basically all temps. They may not be familiar with the facilities they’ve been assigned to, much less the patients, which doesn’t always result in optimal care. And they bid against each other for who will do the job for the lowest rate, creating a race to the bottom for wages. It’s another one of those quote-unquote “advances” that’s a lot less than meets the eye. 

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Special thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Rachel, you’re still on LinkedIn, right? 

Cohrs Zhang: Still on LinkedIn. Still on X. I do have a Bluesky account, too. But any and all the places. 

Rovner: Excellent. Sarah. 

Karlin-Smith: Yeah, I’m at Bluesky, some X, some LinkedIn, @SarahKarlin or @sarahkarlin-smith. 

Rovner: Lauren. 

Weber: I’m still on X, and I am on Bluesky, @LaurenWeberHP. And as a member of — a congressional staffer asked me: Does the “HP” really stand for “health policy”? And yes, it does. So, still there. 

Rovner: Absolutely. We will be back in your feed next week. Until then, be healthy. 

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Layoff notices began arriving early Tuesday for thousands of employees of the sprawling Department of Health and Human Services and its subsidiary agencies, with as many 10,000 workers potentially expected to be hit by the cuts, including some of the country’s top health officials.

The range of job losses across institutes and offices reflected the breadth of what HHS does and the role it plays in the U.S., in both the obvious ways and less appreciated ones. The cuts and reorganizations affected people who help approve new medicines, track emerging pathogens, and uncover the secrets held in our DNA. But they also reached those developing safer tobacco policies, trying to reduce injuries, and protecting people who rely on Medicare and Medicaid — as well as the staff who made the agencies operate day to day and aimed to communicate health updates, new recommendations, and policy shifts to the public. 

Read the rest…

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

As had been rumored for weeks, Health and Human Services Secretary Robert F. Kennedy Jr. unveiled a plan to reorganize the department. It involves the downsizing of its workforce, which formerly was roughly 80,000 people, by a quarter and consolidating dozens of agencies that were created and authorized by Congress.

Meanwhile, in just the past week, HHS abruptly cut off billions in funding to state and local public health departments, and canceled all research studies into covid-19, as well as diseases that could develop into the next pandemic.

This week’s panelists are Julie Rovner of KFF Health News, Maya Goldman of Axios News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Maya Goldman
Axios

@mayagoldman_

Read Maya's stories

Joanne Kenen
Johns Hopkins University and Politico

@JoanneKenen

Read Joanne's stories.

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories.

Among the takeaways from this week’s episode:

• As federal health officials reveal the targets of a significant workforce purge and reorganization, the GOP-controlled Congress has been notably quiet about the Trump administration’s intrusions on its constitutional powers. Many of the administration’s attempts to revoke and reorganize federally funded work are underway despite Congress’ previous approval of that funding. And while changes might be warranted, reviewing how the federal government works (or doesn’t) — in the public forums of congressional hearings and floor debate — is part of Congress’ responsibilities.
• The news of a major reorganization at HHS also comes before the Senate finishes confirming its leadership team. New leaders of the National Institutes of Health and the FDA were confirmed just this week; Mehmet Oz, the nominated director of the Centers for Medicare & Medicaid Services, had not yet been confirmed when HHS made its announcement; and President Donald Trump only recently named a replacement nominee to lead the Centers for Disease Control and Prevention, after withdrawing his first pick.
• While changes early in Trump’s second term have targeted the federal government and workforce, the impacts continue to be felt far outside the nation’s capital. Indeed, cuts to jobs and funding touch every congressional district in the nation. They’re also being felt in research areas that the Trump administration claims as priorities, such as chronic disease: The administration said this week it will shutter the office devoted to studying long covid, a chronic disease that continues to undermine millions of Americans’ health.
• Meanwhile, in the states, doctors in Texas report a rise in cases of children with liver damage due to ingesting too much vitamin A — a supplement pushed by Kennedy in response to the measles outbreak. The governor of West Virginia signed a sweeping ban on food dyes and additives. And a woman in Georgia who experienced a miscarriage was arrested in connection with the improper disposal of fetal remains.

Also this week, Rovner interviews KFF senior vice president Larry Levitt about the 15th anniversary of the signing of the Affordable Care Act and the threats the health law continues to face.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: CNN’s “State Lawmakers Are Looking To Ban Non-Existent ‘Chemtrails.’ It Could Have Real-Life Side Effects,” by Ramishah Maruf and Brandon Miller. 

Alice Miranda Ollstein: The New York Times Wirecutter’s “23andMe Just Filed for Bankruptcy. You Should Delete Your Data Now,” by Max Eddy. 

Maya Goldman: KFF Health News’ “‘I Am Going Through Hell’: Job Loss, Mental Health, and the Fate of Federal Workers,” by Rachana Pradhan and Aneri Pattani. 

Joanne Kenen: The Atlantic’s “America Is Done Pretending About Meat,” by Yasmin Tayag. 

Also mentioned in this week’s podcast:

• The New York Times’ “West Virginia Bans 7 Artificial Food Dyes, Citing Health Concerns,” by Alice Callahan.
• The Washington Post’s “Why I Left My Job Leading Public Health Messaging for the CDC,” by Kevin Griffis.
• Politico’s “The Limits of RFK Jr.’s Power,” by Joanne Kenen.

Click to open the transcript

Transcript: The Ax Falls at HHS

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 27, at 10 a.m. As always, news happens fast — really fast this week — and things might well have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Alice Miranda Ollstein of Politico. 

Alice Miranda Ollstein: Hello. 

Rovner: Maya Goldman of Axios News. 

Maya Goldman: Great to be here. 

Rovner: And Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine. 

Joanne Kenen: Hi everybody. 

Rovner: Later in this episode we’ll have my interview with KFF Senior Vice President Larry Levitt, who will riff on the 15th anniversary of the signing of the Affordable Care Act and what its immediate future might hold. But first, this week’s news. 

So for this second week in a row, we have news breaking literally as we sit down to tape, this time in the form of an announcement from the Department of Health and Human Services with the headline “HHS Announces Transformation to Make America Healthy Again.” The plan calls for 10,000 full-time employees to lose their jobs at HHS, and when combined with early retirement and other reductions, it will reduce the department’s workforce by roughly 25%, from about 82,000 to about 62,000. It calls for creation of a new “Administration for a Healthy America” that will combine a number of existing HHS agencies, including the Health Resources and Services Administration, the Agency for Toxic Substances and Disease Registry, and the National Institute for Occupational Safety and Health under one umbrella. 

Reading through the announcement, a lot of it actually seems to make some sense, as many HHS programs do overlap. But the big overriding question is: Can they really do this? Isn’t this kind of reorganization Congress’ job? 

Ollstein: Congress has not stood up for itself in its power-of-the-purse role so far in the Trump administration. They have stood by, largely, the Republican majorities in the House and Senate, or they’ve offered sort of mild concerns. But they have not said, Hey guys, this is our job, all of these cuts that are happening. There’s talk of a legislative package that would codify the DOGE [Department of Government Efficiency] cuts that are already happening, rubber-stamping it after the fact. But Congress has not made moves to claw back its authority in terms of saying, Hey, we approved this funding, and you can’t just go back and take it. There’s lawsuits to that effect, but not from the members — from outside groups, from labor unions, from impacted folks, but not our dear legislative branch. 

Rovner: You know, Joanne, you were there for a lot of this. We covered the creation of a lot of these agencies. Agency for Healthcare Research and Quality, I covered the creation of its predecessor agency, which there were huge compromises that went into this, lots of policymaking. It just seems that RFK [Robert F. Kennedy] Jr. going to say: We don’t actually care all these things you did. We’re just going to redo the whole thing. 

Kenen: As many of the listeners know, many laws that Congress passes have to be reauthorized every five years or every 10 years. Five is the most typical, and they often don’t get around to it and they extend and blah, blah, blah, blah, blah. But basically the idea is that things do change and things do need to be reevaluated. So, normally when you do reauthorization — we all just got this press release announcing all these mergers of departments and so forth at HHS. None of us are experts in procurement and IT. Maybe those two departments do need to be merged. I mean, I don’t know. That’s the kind of thing that, reauthorization, Congress looks at and Congress thinks about. Well, and agencies and legislation do get updated. Maybe the NIH [National Institutes of Health] doesn’t need 28 institutes and they should have 15 or whatever. But it’s just sort of this, somebody coming in and waving a magic DOGE wand, and Congress is not involved. And there’s not as much public input and expert input as you’d have because Congress holds hearings and listens to people who do have expertise. 

So it’s not just Congress not exercising power to make decisions. It’s also Congress not deliberating and learning. I mean all of us learned health policy partly by listening to experts at congressional panels. We listen to people at Finance, and Energy and Commerce, and so forth. So it’s not just Congress’ voice being silenced. It’s this whole review and fact-based — and experts don’t always agree and Congress makes the final call. But that’s just been short-circuited. And I mean we all know there’s duplication in government, but this isn’t the process we have historically used to address it. 

Rovner: You know, one other thing, I think they’re merging agencies that are in different locations, which on the one hand might make sense. But if you have one central IT or one central procurement agency in Washington or around Washington, you’ve got a lot of these organizations that are outside of Washington. And they’re outside of Washington because members of Congress put them there. A lot of them are in particular places because they were parochial decisions made by Congress. That may or may not make sense, but that’s where they are. It might or might not make sense. Maya, sorry I interrupted you. 

Goldman: No, I was just going to add to Joanne’s point. Julie, I think before we started recording you mentioned that the administration is saying: We’ve thought this all out. These are well-researched decisions. But they’ve been in office for two months. How much research can you really do in that time and how intentional can those decisions really be in that time frame? 

Ollstein: Especially because all of the leaders aren’t even in place yet. Some people were just confirmed, which we’re going to talk about. Some people are on their way to confirmation but not there yet. They haven’t had the chance to talk to career staff, figure out what the redundancies are, figure out what work is currently happening that would be disrupted by various closures and mergers and stuff. So Maya’s exactly right on that. 

Goldman: You know there’s — the administration chose a lead for HRSA and other offices. And so what happens to those positions now? Do they just get demoted effectively because they’re no longer heads of offices? I would be pretty— 

Rovner: But we have a secretary of education whose job is to close the department down, so—. 

Goldman: Good point. 

Rovner: That’s apparently not unprecedented in this administration. Well, as Alice was saying, into this maelstrom of change comes those that President [Donald] Trump has selected to lead these key federal health agencies. The Senate Tuesday night confirmed policy researcher Jay Bhattacharya to head the NIH and Johns Hopkins surgeon and policy analyst Marty Makary to head the Food and Drug Administration. Bhattacharya was approved on a straight party-line vote, while Makary, who I think it’s fair to say was probably the least controversial of the top HHS nominees, won the votes of three Democrats: Minority Whip Dick Durbin of Illinois and New Hampshire’s Democrats, [Sens.] Maggie Hassan and Jeanne Shaheen, along with all of the Republicans. What are any of you watching as these two people take up their new positions? 

Kenen: Well, I mean, the NIH, Bhattacharya — who I hope I’ve learned to pronounce correctly and I apologize if I have not yet mastered it — he’s really always talked about major reorganization, reprioritization. And as I said, maybe it’s time to look at some overlap, and science has changed so much in the last decade or so. I mean are the 28 — I think the number’s 28 — are the 28 current institutes the right— 

Rovner: I think it’s 27. 

Kenen: Twenty-seven. I mean, are there some things that need to be merged or need to be reorganized? Probably. You could make a case for that. But that’s just one thing. The amount of cuts that the administration announced before he got there, and there is a question in some things he’s hinted at, is he going to go for that? His background is in academia, and he does have some understanding of what this money is used for. We’ve talked before, when you talk to a layperson, when you hear the word “overhead,” “indirect costs,” what that conjures up to people as waste, when in fact it’s like paying for the electricity, paying for the staff to comply with the government regulations about ethical research on human beings. It’s not parties. It’s security. It’s cleaning the animal cages. It’s all this stuff. So is he going to cut as deeply as universities have been told to expect? We don’t know yet. And that’s something that every research institution in America is looking at. 

The FDA, he’s a contrarian on certain things but not across the board. I mean, as you just said, Julie, he’s a little less controversial than the others. He is a pancreatic surgeon. He does have a record as a physician. He has never been a regulator, and we don’t know exactly where his contrarian views will be unconventional and where — there’s a lot of agreement with certain things Secretary Kennedy wants to do, not everything. But there is some broad agreement on, some of his food issues do make sense. And the FDA will have a role in that. 

Rovner: I will say that under this reorganization plan the FDA is going to lose 3,500 people, which is a big chunk of its workforce. 

Kenen: Well things like moving SAMHSA [the Substance Abuse and Mental Health Services Administration], which is the agency that works on drug abuse within and drug addiction within HHS, that’s being folded into something else. And that’s been a national priority. The money was voted to help with addiction on a bipartisan basis several times in recent years. The grants to states, that’s all being cut back. The subagency with HHS is being folded into something else. And we don’t know. We know 20,000 jobs are being cut. The 10 announced today and the 10 we already knew about. We don’t know where they’re all coming from and what happens to the expertise and experience addressing something like the addiction crisis and the drug abuse crisis in America, which is not partisan. 

Rovner: All right. Well we’ll get to the cuts in a second. Also on Tuesday, the Senate Finance Committee voted, also along party lines, to advance to the Senate floor the nomination of Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services. And while he would seem likely to get confirmed by the full Senate, I did not have on my bingo card Dr. Oz’s nomination being more in doubt due to Republicans than Democrats. Did anybody else? 

Ollstein: Based on our reporting, it’s not really in doubt. [Sen.] Josh Hawley has raised concerns about Dr. Oz being too squishy on abortion and trans health care, but it does not seem that other Republicans are really jumping on board with that crusade. It sort of reminds me of concerns that were raised about RFK Jr.’s background on abortion that pretty much just fizzled and Republicans overwhelmingly fell in line. And that seems to be what’s going to happen now. Although you never know. 

Rovner: At least it hasn’t been, as you point out, it hasn’t failed anybody else. Well, the one nominee who did not make it through HHS was former Congressman Dave Weldon to head the CDC [Centers for Disease Control and Prevention]. So now we have a new nominee. It’s actually the acting director, Susan Monarez, who by the way has a long history in federal health programs but no history at the CDC. Who can tell us anything about her? 

Goldman: She seems like a very interesting and in some ways unconventional pick, especially for this administration. She was a career civil servant, and she worked under the Obama administration. And it’s interesting to see them be OK with that, I think. And she also has a lot of health care background but not in CDC. She’s done a lot of work on AI in health care and disaster preparedness, I think. And clearly she’s been leading the CDC for the last couple months. So she knows to that extent. But it will be very interesting when she gets around to confirmation hearings to hear what her priorities are, because we really have no idea. 

Rovner: Yeah, she’s not one of those good-on-Fox News people that we’ve seen so many of in this administration. So while Monarez’s nomination seems fairly noncontroversial, at least so far, the nominee to be the new HHS inspector general is definitely not. Remember that President Trump fired HHS IG Christi Grimm just days after he took office, along with the IGs of several other departments. Grimm is still suing to get her job back, since that firing violated the terms of the 1978 Inspector General Act. But now the administration wants to replace her with Thomas Bell, who’s had a number of partisan Republican jobs for what’s traditionally been a very nonpartisan position and who was fired by the state of Virginia in 1997 for apparently mishandling state taxpayer funds. That feels like it might raise some eyebrows as somebody who’s supposed to be in charge of waste, fraud, and abuse. Or am I being naive? 

Goldman: My eyebrows were definitely raised when I saw that news. I, to be honest, don’t know very much about him but will be very interested to see how things go, especially given that fraud, waste, and abuse and rooting out fraud, waste, and abuse are high priorities for this administration, but also things that are very up to interpretation in a certain way. 

Ollstein: Yes, although it’s clearly been very mixed on that front because the administration is also dismantling entire agencies that go after fraud and abuse— 

Goldman: Exactly. 

Ollstein: —like the Consumer Financial Protection Bureau. So there is some mixed messaging on that front for sure. 

Rovner: Well, as Joanne mentioned, the DOGE cuts continue at the NIH. In just the last week, billions of dollars in grants have been terminated that were being used to study AIDS and HIV, covid and other potential pandemic viruses, and climate change, among other things. The NIH also closed its office studying long covid. Thank you, Alice, for writing that story. This is, I repeat, not normal. NIH only generally cancels grants that have been peer reviewed and approved for reasons of fraud or scientific misconduct, yet one termination letter obtained by Science Magazine simply stated, quote, “The end of the pandemic provides cause to terminate COVID-related grant funds.” Why aren’t we hearing more about this, particularly for members of Congress whose universities are the ones that are being cut? 

Kenen: I mean, the one Republican we heard at the very beginning was [Sen.] Katie Britt because the University of Alabama is a big, excellent, and well-respected national medical and science center, and they were targeted for a lot of cuts. She’s the only Republican, really, and she got quiet. I mean, she raised her voice very loud and clear. We may go into a situation — and everybody sort of knows this is how Washington sometimes works — where individual universities will end up negotiating with NIH over their funds and that— 

Rovner: Columbia. Cough, cough. 

Kenen: Right. And Alabama may come out great and Columbia might not, or many other leading research institutions. But these job cuts affect people in every congressional district across the country. And the funding cuts affect every congressional district across the country. So it’s not just their constitutional responsibilities. It’s also, like, their constituents are affected, and we’re not hearing it. 

Rovner: And as I point out for the millionth time, it’s not a coincidence that these things are located in every congressional district. Members of Congress, if not the ones who are currently in office then their predecessors, lobbied and worked to get these funds to their states and to their district. And yet the silence is deafening. 

Ollstein: To state the obvious, one, covid is not over. People are still contracting it. People are still dying from it. But not only that, a lot of this research was about preparing for the inevitable next pandemic that we know is coming at some point and to not be caught as unawares as we were this past time, to be more prepared, to have better tools so that there don’t have to be widespread lockdowns, things can remain open because we have more effective prevention and treatment efforts. And that’s what’s being defunded here. 

Kenen: The other thing is that long covid is in fact a chronic disease and even though it’s caused by an infectious disease, a virus. But people have long covid but it is a chronic disease, and HHS says that’s their priority, chronic disease, but they’re not including long covid. And there’s also more and more. When we think of long covid, we think of brain fog and being short of breath and tired and unable to function. There’s increasing evidence or conversation in the medical world about other problems people have long-term that probably stem from covid infections or multiple covid infections. So this is affecting millions of Americans as a chronic disease that is not well understood, and we’ve just basically said, That one doesn’t count, or: We’re not going to pay attention to that one. We’re going to, you know, we’re looking at diabetes. Yeah, we need to look at diabetes. That’s one of the things that Kennedy has bipartisan support. This country does not eat well. I wrote about this about a week ago. But what he can and can’t do, because he can’t wave a magic wand and have us all eating well. But it’s very selective in how we’re defining both the causes of diseases and what diseases we’re prioritizing. We basically just shrunk addiction. 

Goldman: In the press release announcing the reorganization this morning, there was a line talking about how the HHS is going to create this new Administration for a Healthy America to investigate chronic disease and to make sure that we have, I think it was, wholesome food, clean water, and no environmental toxins, in order to prevent chronic disease. And those are the only three things that it mentions that lead to chronic disease. 

Rovner: And none of which are under HHS’ purview. 

Goldman: Right, right. Yeah. 

Rovner: With the exception of— 

Goldman: There are things that HHS does in that space. But yeah, we’re being very selective about what constitutes a chronic disease and what causes a chronic disease. If you’re trying to actually solve a problem, maybe you should be more expansive. 

Kenen: So HHS has some authority over food, not significant authority of it, but it is shared with the USDA [U.S. Department of Agriculture]. Like school lunches are USDA, the nutritional guidelines are shared between USDA and HHS, things like that. So yeah, it has some control about, over food but not entirely control over food. 

And then EPA [Environmental Protection Agency], which has also been completely reoriented to be a pro-fossil-fuel agency, is in charge of clean water and the environmental contaminants. That’s not an HHS bailiwick. And Kennedy is not aligned with other elements of the administration on environmental issues. And also genetics, right? Genetics is also, you know, who knows? That’s NIH? But who knows what’s going to happen to the National Cancer Institute and other genetic research at NIH? We don’t know. 

Rovner: Yes. Clearly much to be determined. Well, speaking of members of Congress whose states and districts are losing federal funds, federal aid is also being cut by the CDC. In a story first reported by NBC News, CDC is reportedly clawing back more than $11 billion in covid-related grants. Among other things, that’s impacting funding that was being used in Texas to fight the ongoing measles outbreak. How exactly does clawing back this money from state and local public health agencies make America healthy again? 

Goldman: That’s a great question, and I’m curious to see how it plays out. I don’t have the answer. 

Rovner: And it’s not just domestic spending. The fate of PEPFAR [the President’s Emergency Plan for AIDS Relief], the international AIDS/HIV program that’s credited with saving more than 20 million lives, remains in question. And The New York Times has gotten hold of a spreadsheet including more global health cuts, including those for projects to fight malaria and to pull the U.S. out of Gavi. That’s the global vaccine alliance that’s helped vaccinate more than 1.1 billion children in 78 countries. Wasn’t there a court order stopping all of these cuts? 

Ollstein: So there was for some USAID [U.S. Agency for International Development] work, but not all of these things fall under that umbrella. And that is still an ongoing saga that has flipped back and forth depending on various rulings. But I think it’s worth pointing out, as always, that infectious diseases don’t respect international borders, and any pullback on efforts to fight various things abroad inevitably will impact Americans as well. 

Rovner: Yeah. I mean, we’ve seen these measles cases obviously in Texas, but now we’re getting measles cases in other parts of the country, and many of them are people coming from other countries. We had somebody come through Washington, D.C.’s Union Station with measles, and we’ve had all of these alerts. I mean, this is what happens when you don’t try and work with infectious diseases where they are, then they spread. That’s kind of the nature of infectious disease. 

Well, at the same time, HHS Secretary RFK Jr. is putting his Make America Healthy Again agenda into practice in smaller ways as well. First up, remember that study that Kennedy promised again to look into any links between childhood vaccines and autism? It will reportedly be led by a vaccine skeptic who was disciplined by the Maryland Board of Physicians for practicing medicine without a license and who has pushed the repeatedly debunked assertion that autism can be caused by the preservative thimerosal, which used to be used in childhood vaccines but has long since been discontinued. One autism group referred to the person who’s going to be running this study as, quote, “a known conspiracy theorist and quack.” Sen. [Bill] Cassidy seemed to promise us that this wasn’t going to happen. 

Kenen: Well, we think that Sen. Cassidy was promised it wouldn’t happen, and it’s all happening. And in fact, when a recent hearing, he was very outspoken that there’s no need to research the autism link, because it’s been researched over and over and over and over and over again and there’s a lot of reputable scientific evidence establishing that vaccination does not cause autism. We don’t know what causes autism, so— 

Rovner: But we know it’s not thimerosal. 

Kenen: Right, which has been removed from many vaccines, in fact, and autism rates went up. So Cassidy has not come out and said, Yeah, I’m the guy who pulled the plug on Weldon. But it’s sort of obvious that he had, at least was, a role in. It is widely understood in Washington that he and a few other Republicans, [Sens. Lisa] Murkowski and [Susan] Collins, I believe — I think Murkowski said it in public — said that the CDC could not go down that route. 

Rovner: Well, I would like to be inadvertently invited to the Signal chat between Secretary Kennedy and Sen. Cassidy. I would very much wish to see that conversation. 

Meanwhile, in Texas, where HHS just confiscated public health funding, as we said, a hospital in Lubbock says it’s now treating children with liver damage from too much vitamin A, which Secretary Kennedy recommended as a way to prevent and or treat measles. Which it doesn’t, by the way. But that points to, that some of these — I hesitate of how to describe these people who are “making America healthy again.” But some of the things that they point to can be actively dangerous, not just not helpful. 

Goldman: Yeah. And I think it also shows how much messaging from the top matters, right? People are listening to what Secretary Kennedy says, which makes sense because he’s the secretary of health and human services. But if he’s pedaling misinformation or disinformation, that can have real harmful effects on people. 

Kenen: And his messages are being amplified even if some people are not, their parents, who aren’t maybe directly tuned in to what Kennedy personally is saying, but they follow various influencers on health who are then echoing what Kennedy’s saying about vitamin A. Yeah, we all need vitamin A in our diet. It’s something, part of healthy nutrition. But this supplement’s unnecessary, or excess supplements, vitamin A or cod liver oil or other things that can make them sick, including liver damage. And that’s what we’re seeing now. Vitamin A does have a place in measles under very specific circumstances, under medical supervision in individual cases. But no, people should not be going to the drugstore and pouring huge numbers of tablets of vitamin C down their children’s throat. It’s dangerous. 

Rovner: And actually the head of communications at the CDC not only quit his job this week but wrote a rather impassioned op-ed in The Washington Post, which I will post in our show notes, talking about he feels like he cannot work for an agency that is not giving advice that is based in science and that that’s what he feels right now. Again, that’s before we get a new head of the CDC. Well, MAHA is apparently spreading to the states as well. West Virginia Republican Gov. Patrick Morrisey this week signed a bill to ban most artificial food coloring and two preservatives in all foods sold in the state starting in 2028. Nearly half the rest of the states are considering similar types of bans. But unless most of those other states follow, companies aren’t going to remake their products just for West Virginia, right? 

Kenen: West Virginia is not big enough, but they sometimes do remake their products for California, which is big. The whole food additive issue is, traditionally the food manufacturers have had a lot of control over deciding what’s safe. It’s the industry that has decided. Kennedy has some support across the board and saying that’s too loose and we should look at some of these additives that have not been examined. There are others, including some preservatives, that have been studied and that are safe. Some preservatives have not been studied and should be studied. There are others that have been studied and are safe and they keep food from going rotten or they can prevent foodborne disease outbreaks. Something that does make our food healthy, we probably want to keep them in there. So, and are there some that— 

Rovner: I think people get mixed up between the dyes and the preservatives. Dyes are just to make things look more attractive. The preservatives were put there for a reason. 

Kenen: Right. And there’s some healthy ways of making dyes, too, if you need your food to be red. There’s berry abstracts instead of chemical extracts. So things get overly simplified in a way that does not end up necessarily promoting health across the board. 

Rovner: Well, not all of the news is coming from the Trump administration. The Supreme Court next week will hear a case out of South Carolina about whether Medicaid recipients can sue to enforce their right to get care from any qualified health care providers. But this is really another case about Planned Parenthood, right, Alice? 

Ollstein: Yep. If South Carolina gets the green light to kick Planned Parenthood out of its Medicaid program, which is really what is at the heart of this case, even though it’s sort of about whether beneficiaries can sue if their rights are denied. A right isn’t a right if you can’t enforce it, so it’s expected that a ruling in that direction would cause a stampede of other conservative states to do the same, to exclude Planned Parenthood from their Medicaid programs. Many have tried already, and that’s gone around and around in the courts for a while, and so this is really the big showdown at the high court to really decide this. 

And as I’ve been writing about, this is just one of many prongs of the right’s bigger strategy to defund Planned Parenthood. So there are efforts at the federal level. There are efforts at the state level. There are efforts in the courts. They are pushing executive actions on that front. We can talk. There was some news on Title X this week. 

Rovner: That was my next question. Go ahead. 

Ollstein: Some potential news. 

Rovner: What’s happening with Title X? 

Ollstein: Yeah. So HHS told us when we inquired that nothing’s final yet, but they’re reviewing tens of millions of Title X federal family planning grants that currently go to some Planned Parenthood affiliates to provide subsidized contraception, STI [sexually transmitted infection] screenings, various non-abortion services. And so they are reviewing those grants now. They are supposed to be going out next week, so we’ll have to see what happens there. There was some sort of back-and-forth in the reporting about whether they’re going to be cut or not. 

Rovner: What surprises me about the Title X grant, and there has been, there have been efforts, as you point out, going back to the 1980s to kick Planned Parenthood out of the Title X program. That’s separate from kicking Planned Parenthood out of Medicaid, which is where Planned Parenthood gets a lot more money. 

But the first Trump administration did kick Planned Parenthood out of Title X, and they went through the regulatory process to do it. And then the Biden administration went through the regulatory process to rescind the Trump administration regulations that kicked them out. Now it looks like the Trump administration thinks that it can just stop it without going through the regulatory process, right? 

Ollstein: That’s right. So not only are they going around Congress, which approves Title X funding every year, they are also going around their own rulemaking and just going for it. Although, again, it has not been finally announced whether or not there will be cuts. They’re just reviewing these grants. 

Rovner: But I repeat for those in the back, this is not normal. It’s not how these things are supposed to work it. 

Kenen: It’s normal now, Julie. 

Rovner: Yeah, clearly it’s becoming normal. Well, finally this week, another case of a woman arrested for a poor pregnancy outcome. This happened in Georgia where the woman suffered a natural miscarriage, not an abortion, which was confirmed by the medical examiner, but has been arrested on charges of improperly disposing of the fetal remains. Alice, this is turning into a trend, right? 

Ollstein: Yes. And it’s important for people to remember that this was happening before Dobbs. This was happening when Roe v. Wade was still in place. This has happened since then in states where abortion is legal. Some prosecutors are finding other ways to charge people. Whether it’s related to, yeah, the disposal of the fetus, whether it’s related to substance abuse, substance use during pregnancy, even sometimes the use of substances that are actually legal, but people have been charged, arrested for using them during pregnancy. So yes, it’s important to remember that even if there’s not a quote-unquote “abortion ban” on the books, there are still efforts underway in many places to criminalize pregnancy loss however it happens, naturally or via some abortifacient method. 

Rovner: Well, something else we’ll be keeping an eye on. All right, that’s as much news as we have time for this week. Now, we will play my interview with KFF’s Larry Levitt. Then we’ll come back and do our extra credits. 

So, last Sunday was the 15th anniversary of President Barack Obama’s signing of the original Affordable Care Act. And before you ask, yes, I was there in the White House East Room that day. Anyway, to discuss what the law has meant to the U.S. health system over the last decade and a half and what its future might be, I am so pleased to welcome back to the podcast my KFF colleague Larry Levitt, executive vice president for health policy. 

Larry, thanks for joining us again. 

Larry Levitt: Oh, thanks for having me. 

Rovner: So, [then-House Speaker] Nancy Pelosi was mercilessly derided when she said that once the American people learned exactly what was in the ACA, they would come to like it. But that’s exactly what’s happened, right? 

Levitt: It is. Yes. I think people took her comments so out of context, but the ACA was incredibly controversial and divisive when it was being debated. Frankly, after a pass, the ACA became pretty unpopular. If you go back to 2014, just before the main provisions of the ACA were being implemented, there was all this controversy over the individual mandate, over people’s plans being canceled because they didn’t comply with the ACA’s rules. And then, of course, healthcare.gov, the website, didn’t work. So the ACA was very underwater in public opinion. And even after it first went into effect and people started getting coverage, that didn’t necessarily turn around immediately, there was still a lot of divisiveness over the law. 

What changed is, No. 1, over time, more and more people got covered, people with preexisting conditions, people who couldn’t afford health insurance, people who turned 26 or could stay on their parents’ plans until 26 and then could enroll in the ACA or Medicaid after turning 26. All these people got coverage and started to see the benefits of the law. The other thing that happened was in 2017, Republicans tried unsuccessfully to repeal and replace the ACA, and people really realized what they could be missing if the law went away. 

Rovner: So what’s turned out to be the biggest change to the health care system as a result of the ACA? And is it what you originally thought it would be? 

Levitt: Well, yeah, in this case it was not a surprise, I think. The biggest change was the number of people getting covered and a big decrease in the number of people uninsured. We have been at the lowest rate of uninsurance ever recently due to the ACA and some of the enhancements, which we’ll probably talk about. And that was what the law was intended to do, was to get more people covered. And I think you’d have to call that a success, in retrospect. 

Rovner: I will say I was surprised by how much Medicaid dominated the increased coverage. I know now it’s sort of balanced out because of reductions in premiums for private coverage, I think in large part. But I think during the 2017 fight to undo the ACA, that was the first time since I’ve been covering Medicaid that I think people really realized how big and how important Medicaid is to the health care system. 

Levitt: No, that’s right. I mean the ACA marketplace, healthcare.gov, the individual mandate, preexisting condition protections, I mean, those are the things that got a lot of the public attention. But in fact, yeah, in the early years of the ACA, I mean really up until just the last couple years, the Medicaid expansion in the ACA was really the engine of coverage. And that’s not what a lot of people expected. In fact, Congressional Budget Office in their original projections kind of got that wrong, too. 

Rovner: So what was the biggest disappointment about something the ACA was supposed to do but didn’t do or didn’t do very well? 

Levitt: Yeah, I mean, I would have to point to health care costs as the biggest disappointment. The ACA really wasn’t intended to address health care costs head-on. And that was both a policy judgment but also a political decision. If you go back to the debate over the Clinton health plan in the early ’90s, which failed spectacularly — you and I were both there — it addressed health care costs aggressively, took on every segment of the health care industry, and died under that political weight. The political judgment of Obama and Democrats in Congress with the ACA was to not take on those vested health care interests and not really address health care costs head-on. That’s what enabled it to get passed. But it sort of lacked teeth in that regard. There were some things in the ACA like expansion of ACOs, accountable care organizations, which maybe had some promise but frankly have not done a whole lot. 

Rovner: And of course, Congress undoing what teeth there were in the ensuing years probably didn’t help very much, either. 

Levitt: No. I mean there was this provision in the ACA called the Cadillac plan tax, right? The idea was to tax so-called Cadillac health plans, very generous health plans. That probably would’ve had an effect. I’m not sure it would’ve done what people intended for it to do. I mean, I think it would’ve actually shifted costs to workers and caused deductibles to rise even higher. But no one but economists liked that Cadillac plan tax, and it was repealed. 

Rovner: So, as you mentioned, you and I are both also veterans of the 1993, 1994 failed effort by President Bill Clinton to overhaul the nation’s health care system, which, like the fight over the ACA, featured large-scale, deliberate mis- and disinformation by opponents about what a major piece of health legislation could do. In fact, and I have done lots of stories on this, scare tactics about the possible impact of providing universal health insurance coverage date back to the early 1900s and have been a feature of every single major health care debate since then. What did we learn from the ACA debate about combating this kind of deliberate misinformation? 

Levitt: Yeah, you’re so right about the disinformation, and I was actually looking yesterday — we have a timeline of health policy over the decades in our KFF headquarters in San Francisco, and we have an ad up there from the debate over the Truman health plan. You and I were not there for that debate. 

Rovner: Thank you. 

Levitt: And the AMA [American Medical Association] opposed that as socialized medicine and ran these ads featuring robots who were going to be your doctor if the Truman plan passed. So this is certainly nothing new. And we saw it in the ACA with death panels, right? I mean, which just spread like wildfire through the media and over social media. I would kind of hope we learned some lessons from the ACA. I’m not sure we have. And I kind of worry that with declining trust in institutions, particularly government institutions, I just wonder whether we’ll get back to a place where, yeah, we’ll disagree about policy. There will be spin, there will be scare tactics, but at least there’s some trusted source of facts and data that we can rely on, and I’m not so hopeful there. 

Rovner: Somebody asked former [HHS] Secretary Kathleen Sebelius at a 15th-anniversary event what she regretted most about not having in the ACA, and she said, With all the talk of our actually taking over the health care system, we should have just taken over the health care system, since that’s what everybody was accusing it of. It might’ve worked better. 

Levitt: Yeah, there is — we could have a whole other session on “Medicare for All” and single payer and the pros and cons of that. But one thing I think we did learn from the ACA, that complexity is just a huge problem. Even what’s supposed to be the simplest part of our health care system now, Medicare, has become incredibly complex with Part A and Part B and Part C and Part D. Seniors kind of scratch their heads trying to figure out what to do, and the ACA even more so. 

And I think back to your original question, part of what made the ACA so hard for people to grasp is there was not one single, Oh, I’m going to sign up for the ACA. There were so many pieces of it. And over time, I’m not even sure people identify those pieces with the ACA anymore. 

Rovner: Yeah. Oh, no, I am surprised at how many younger people have no idea of what the insurance market was like before the ACA and how many people were simply redlined out of getting coverage. 

Levitt: Right. No. I mean, once you fix those problems, then people don’t see them anymore. 

Rovner: So let’s look forward quickly. It seemed at least for a while after the Republicans failed in 2017 to repeal and replace the law that efforts to undo it were finally over. But while this administration isn’t saying directly that they want to end it, they do have some big targets for undoing big pieces of it. What are some of those and what are the likelihood of them happening? 

Levitt: Yeah, in some ways we have an ACA repeal-and-replace debate going on right now, just not in name. And there are really kind of two big pieces on the table. One, of course, is potential cuts to Medicaid. The House has passed a budget resolution calling for $880 billion in cuts, by the Energy and Commerce Committee, which has jurisdiction over Medicaid. The vast majority of those cuts would have to be in Medicaid. The math is simply inescapable. And a big target on the table is that expansion of Medicaid that was in the ACA. 

And interestingly, you’re even hearing Republicans on the Hill talking about repealing the enhanced federal matching payments for the ACA Medicaid expansion and saying: Well, that’s not Medicaid cuts. That’s Obamacare. That’s not Medicaid. But 20 million people are covered under that Medicaid expansion. So it would lead to the biggest increase in the number of people uninsured we’ve ever had, if that gets repealed. 

The other issue really has not gotten a lot of attention yet this year, which is the extra premium assistance that was passed under [President Joe] Biden and by Democrats in Congress. And that’s led to a dramatic increase in ACA marketplace enrollment. ACA enrollment has more than doubled to 24 million since 2020. Those subsidies expire at the end of this year. So if Congress does nothing, people would be faced with very big out-of-pocket premium increases. And I suspect it’s going to get more attention as we get closer to the end of the year, but so far there hasn’t been a big debate over it yet. 

Rovner: Well, we’ll continue to talk about it. Larry Levitt, thank you so much. 

Levitt: Oh, thanks. Great conversation. 

Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Joanne, why don’t you go first this week? 

Kenen: There’s a piece in The Atlantic this week called “America Is Done Pretending About Meat,” by Yasmin Tayag, and it’s basically saying that half of the people who said they were vegan or vegetarian were lying and that meat is very much back in fashion. That the new pejorative term — some of us may remember from 20 years or so ago, the “quiche eaters” —now it’s the “soy boy.” And that one of the new “in” foods, and I think this is the first for the podcast to use the phrase, raw beef testicles. So when we’re talking about political red meat, it’s not just political red meat. America is, we’re eating a lot more meat than we said we did, and we’re no longer saying that we’re not eating it. 

Rovner: Real red meat for the masses. 

Ollstein: For what it’s worth, “soy boy” has been a slur since the Obama administration. 

Kenen: Well, it’s just new to me. Thank you. I welcome the— 

Ollstein: I unfortunately have been in the online fever swamps where people say things like that. 

Kenen: Thank you, Alice. Now I know. 

Rovner: Maya, why don’t you go next? 

Goldman: My extra credit is a KFF Health News article by Rachana Pradhan and Aneri Pattani called “‘I Am Going Through Hell’: Job Loss, Mental Health, and the Fate of Federal Workers.” And I think it’s just worth remembering that there are real consequences, real mental health consequences to mass upheaval at the scale of what’s going on in the federal government right now with so many people losing their jobs and just not sure if their jobs are stable, especially in light of this morning’s news about HHS reorganizations. But also I think this article does a really good job of highlighting how this chaos and instability is only going to exacerbate already ongoing mental health crises that some of these workers that have been laid off were trying to help solve. And so it’s just this cycle that keeps running through. It’s worth remembering. 

Rovner: The chaos is the point. Alice. 

Ollstein: So, I have a piece from the New York Times Wirecutter section called “23andMe Just Filed for Bankruptcy. You Should Delete Your Data Now.” And it’s what it says. The company that millions and millions of people have sent samples of their DNA to over the years to find out what percent European they are and all this stuff and their propensity for various inherited diseases, that company is going bankrupt, and there is the expectation that it will be sold off for parts, including people’s very sensitive DNA. And the article points out that because they are not a health care provider, they are not subject to HIPAA [Health Insurance Portability and Accountability Act]. And so many elected officials and privacy advocates are recommending that people, very quickly, if they have given their DNA to this company, go and delete their information now before it gets sold off to who knows who. 

Rovner: And for who knows what reason. My extra credit this week is something I really did think at first was from The Onion. It’s actually from CNN, and it’s called “State Lawmakers Are Looking to Ban Non-Existent ‘Chemtrails.’ It Could Have Real-Life Side Effects,” by Ramishah Maruf and Brandon Miller, who’s a CNN meteorologist. It seems that several states are moving to ban those white lines the jets leave behind them, on the theory that they are full of toxic chemicals and/or intended to manipulate the weather. In fact, they’re mostly just water vapor. They’re called contrails because the con is for condensation. But these laws could outlaw some new types of technologies that are aimed at addressing things like climate change. Clearly we need to teach more science along with more civics. 

OK, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcast. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks, as always, to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you could email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you folks hanging these days? Maya? 

Goldman: I am on X and Bluesky. If you search Maya Goldman, you’ll find me. And also increasingly on LinkedIn. Find me there. 

Rovner: Hearing that a lot. Alice. 

Ollstein: I am on X, @AliceOllstein, and Bluesky, @alicemiranda. 

Rovner: Joanne. 

Kenen: I’m mostly at Bluesky, and I’m also using LinkedIn a lot. @joannekenen at Bluesky. LinkedIn is reverberating more. 

Rovner: All right, we’ll be back in your feed next week with still more breaking news. Until then, be healthy. 

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

Two months into the new administration, federal workers and contractors remain off-balance as the Trump administration ramps up its efforts to cancel jobs and programs — even as federal judges declare many of those efforts illegal and/or unconstitutional.

As it eliminates programs deemed duplicative or unnecessary, however, President Donald Trump’s Department of Government Efficiency is also cutting programs and workers aligned with Health and Human Services Secretary Robert F. Kennedy Jr.’s “Make America Healthy Again” agenda.

This week’s panelists are Julie Rovner of KFF Health News, Jessie Hellmann of CQ Roll Call, Sarah Karlin-Smith of the Pink Sheet, and Rachel Roubein of The Washington Post.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories.

Sarah Karlin-Smith
Pink Sheet

@SarahKarlin

Read Sarah's stories.

Rachel Roubein
The Washington Post

@rachel_roubein

Read Rachel's stories.

Among the takeaways from this week’s episode:

• Kennedy’s comments this week about allowing bird flu to spread unchecked through farms provided another example of the new secretary of health and human services making claims that lack scientific support and could instead undermine public health.
• The Trump administration is experiencing more pushback from the federal courts over its efforts to reduce and dismantle federal agencies, and federal workers who have been rehired under court orders report returning to uncertainty and instability within government agencies.
• The second Trump administration is signaling it plans to dismantle HIV prevention programs in the United States, including efforts that the first Trump administration started. A Texas midwife is accused of performing illegal abortions. And a Trump appointee resigns after being targeted by a Republican senator.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: The Washington Post’s “The Free-Living Bureaucrat,” by Michael Lewis.

Rachel Roubein: The Washington Post’s “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” by Carolyn Y. Johnson.

Sarah Karlin-Smith: KFF Health News’ “Scientists Say NIH Officials Told Them To Scrub mRNA References on Grants,” by Arthur Allen.

Jessie Hellmann: Stat’s “NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease,” by Elaine Chen.

Also mentioned in this week’s podcast:

• The Wall Street Journal’s “Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention,” by Liz Essley White, Dominique Mosbergen, and Jonathan D. Rockoff.
• The Washington Post’s “Disabled Americans Fear Losing Protections if States’ Lawsuit Succeeds,” by Amanda Morris.

click to open the transcript

Transcript: Federal Health Work in Flux

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.] 

Julie Rovner: Hello, and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, March 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go. 

Today we are joined via videoconference by Rachel Roubein of The Washington Post. 

Rachel Roubein: Hi. 

Rovner: Sarah Karlin-Smith of the Pink Sheet. 

Sarah Karlin-Smith: Hi, everybody. 

Rovner: And Jessie Hellmann of CQ Roll Call. 

Jessie Hellmann: Hello. 

Rovner: No interview today, but, as usual, way more news than we can get to, so let us jump right in. In case you missed it, there’s a bonus podcast episode in your feed. After last week’s Senate Finance Committee confirmation hearing for Dr. Mehmet Oz to head the Centers for Medicare & Medicaid Services, my KFF Health News colleagues Stephanie Armour and Rachana Pradhan and I summarized the hearing and caught up on all the HHS [Department of Health and Human Services] nomination actions. It will be the episode in your feed right before this one. 

So even without Senate-confirmed heads at — checks notes — all of the major agencies at HHS, the department does continue to make news. First, Robert F. Kennedy Jr., the new HHS secretary, speaks. Last week it was measles. This week it was bird flu, which he says should be allowed to spread unchecked in chicken flocks to see which birds are resistant or immune. This feels kind of like what some people recommended during covid. Sarah, is there any science to suggest this might be a good idea? 

Karlin-Smith: No, it seems like the science actually suggests the opposite, because doctors and veterinary specialists are saying basically every time you let the infection continue to infect birds, you’re giving the virus more and more chances to mutate, which can lead to more problems down the road. The other thing is they were talking about the way we raise animals, and for food these days, there isn’t going to be a lot of genetic variation for the chickens, so it’s not like you’re going to be able to find a huge subset of them that are going to survive bird flu. 

And then the other thing I thought is really interesting is just it doesn’t seem economically to make the most sense either as well, both for the individual farmers but then for U.S. industry as a whole, because it seems like other countries will be particularly unhappy with us and even maybe put prohibitions on trading with us or those products due to the spread of bird flu. 

Rovner: Yeah, it was eyebrow-raising, let us say. Well, HHS this week also announced its first big policy effort, called Operation Stork Speed. It will press infant formula makers for more complete lists of ingredients, increase testing for heavy metals in formula, make it easier to import formula from other countries, and order more research into the health outcomes of feeding infant formula. This feels like maybe one of those things that’s not totally controversial, except for the part that the FDA [Food and Drug Administration] workers who have been monitoring the infant formula shortage were part of the big DOGE [Department of Government Efficiency] layoffs. 

Roubein: I talked to some experts about this idea, and, like you said, they thought it kind of sounded good, but they basically needed more details. Like, what does it mean? Who’s going to review these ingredients? To your point, some people did say that the agency would need to staff up, and there was a neonatologist who is heading up infant formula that was hired after the 2022 shortage who was part of the probationary worker terminations. However, when the FDA rescinded the terminations of some workers, so, that doctor has been hired back. So I think that’s worth noting. 

Rovner: Yes. This is also, I guess, where we get to note that Calley Means, one of RFK Jr.’s, I guess, brain trusts in the MAHA movement, has been hired as, I guess, in an Elon Musk-like position in the White House as an adviser. But this is certainly an area where he would expect to weigh in. 

Hellmann: Yeah, I saw he’s really excited about this on Twitter, or X. There’s just been concerns in the MAHA movement, “Make America Healthy Again,” about the ingredients that are in baby formula. And the only thing is I saw that he also retweeted somebody who said that “breast is best,” and I’m just hoping that we’re not going back down that road again, because I feel like public health did a lot of work in pushing the message that formula and breast milk is good for the child, and so that’s just another angle that I’ve been thinking about on this. 

Rovner: Yes, I think this is one of those things that everybody agrees we should look at and has the potential to get really controversial at some point. While we are on the subject of the federal workforce and layoffs, federal judges and DOGE continue to play cat-and-mouse, with lots of real people’s lives and careers at stake. Various judges have ordered the reinstatement, as you mentioned, Rachel, of probationary and other workers. Although in many cases workers have been reinstated to an administrative leave status, meaning they get put back on the payroll and they get their benefits back, but they still can’t do their jobs. At least one judge has said that does not satisfy his order, and this is all changing so fast it’s basically impossible to keep up. But is it fair to say that it’s not a very stable time to be a federal worker? 

Karlin-Smith: That’s probably the nicest possible way to put it. When you talk to federal workers, everybody seems stressed and just unsure of their status. And if they do have a job, it’s often from their perspective tougher to do their job lately, and then they’re just not sure how stable it is. And many people are considering what options they have outside the federal government at this point. 

Rovner: So for those lucky federal workers who do still have jobs, the Trump administration has also ordered everyone back to offices, even if those offices aren’t equipped to accommodate them. FDA headquarters here in Maryland’s kind of been the poster child for this this week. 

Karlin-Smith: Yeah, FDA is an interesting one because well before covid normalized working from home and transitioned a lot of people to working from home, FDA’s headquarters couldn’t accommodate a lot of the new growth in the agency over the years, like the tobacco part of the FDA. So it was typical that people at least worked part of their workweek at home, and FDA really found once covid gave them additional work-from-home flexibilities, they were able to recruit staff they really, really needed with specialized degrees and training who don’t live near here, and it actually turned out to be quite a benefit from them. 

And now they’re saying everybody needs to be in an office five days a week, and you have people basically cramped into conference rooms. There’s not enough parking. People are trying to review technical scientific data, and you kind of can’t hear yourself think. Or you’re a lawyer — I heard of a situation where people are basically being told, Well, if you need to do a private phone call because of the confidentiality around what you’re doing, go take the call in your car. So I think in addition to all of the concerns people have around the stability of their jobs, there’s now this element of, on a personal level, I think for many of them it’s just made their lives more challenging. And then they just feel like they’re not actually able to do, have the same level of efficiency at their work as they normally would. 

Rovner: And for those who don’t know, the FDA campus is on a former military installation in the Maryland suburbs. It’s not really near any public transportation. So you pretty much have to drive to get there. And I think that the parking lots are not that big, because, as you pointed out, Sarah, the workforce is now bigger than the headquarters was created to accommodate it. And we’re seeing this across the government. This week it happened to be FDA. You have to ask the question: Is this really just an effort to make the government not work, to make federal workers, if they can’t fire them, to make them quit? 

Hellmann: I definitely think that’s part of the underlying goal. If you see some of the stuff that Elon Musk says about the federal workforce, it’s very dismissive. He doesn’t seem to have a lot of respect for the civil servants. And they’ve been running into a lot of pushback from federal judges over many lawsuits targeting these terminations. And so I think just making conditions as frustrating as possible for some of these workers until they quit is definitely part of the strategy. 

Roubein: And I think this is overlaid with the additional buyout offers, the additional early retirement offers. There’s also the reduction-in-force plans that federal workers have been unnerved about, bracing for future layoffs. So it’s very clear that they want to shrink the size of the federal workforce. 

Rovner: Yeah, we’ve seen a lot of these people, I’ve seen interviews with them, who are being reinstated, but they’re still worried that now they’re going to be RIF-ed. They’re back on the payroll, they’re off the payroll. I mean there’s nothing — this does not feel like a very efficient way to run the federal government. 

Karlin-Smith: Right. I think that’s what a lot of people are talking about is, again, going back to offices, for many of these people, is not leading to productivity. I talked to one person who said: I’m just leaving my laptop at the office now. I’m not going to take it home and do the extra hours of work that they might’ve normally gotten from me. And that includes losing time to commute. FDA is paying for parking-garage spaces in downtown Silver Spring [Maryland] near the Metro so that they can then shuttle people to the FDA headquarters. I’ve taken buses from that Metro to FDA headquarters. In traffic, that’s a 30-minute drive. They’re spending money on things that, again, I think are not going to in the long run create any government efficiency. 

And in fact, I’ve been talking to people who are worried it’s going to do the opposite, that drug review, device review, medical product review times and things like that are going to slow. We talked about food safety. I think The New York Times had a really good story this week about concerns about losing the people. We need to make sure that baby formula is actually safe. So there’s a lot of contradictions in the messaging of what they’re trying to accomplish and how the actions actually are playing out. 

Rovner: Well, and finally, I’m going to lay one more layer on this. There’s the question of whether you can even put the toothpaste back in the tube if you wanted to. After weeks of back-and-forth, the federal judge ruled on Tuesday that the dissolution of USAID [the U.S. Agency for International Development] was illegal and probably unconstitutional, and ordered email and computer access restored for the remaining workers while blocking further cuts. But with nearly everybody fired, called back from overseas, and contracts canceled, USAID couldn’t possibly come close to doing what it did before DOGE basically took it apart, right?. 

Karlin-Smith: You hear stories of if someone already takes a new job, they’re lucky enough to find a new job, why are they going to come back? Again, even if you’re brought back, my expectation is a lot of people who have been brought back are probably looking for new jobs regardless because you don’t have that stability. And I think the USAID thing is interesting, too, because again, you have people that were working in all corners of the world and you have partnerships with other countries and contractors that have to be able to trust you moving forward. And the question is, do those countries and those organizations want to continue working with the U.S. if they can’t have that sort of trust? And as people said, the U.S. government was known as, they could pay contractors less because they always paid you. And when you take that away, that creates a lot of problems for negotiating deals to work with them moving forward. 

Rovner: And I think that’s true for federal workers, too. There’s always been the idea that you probably could earn more in the private sector than you can working for the federal government, but it’s always been a pretty stable job. And I think right now it’s anything but, so comes the question of: Are we deterring people from wanting to work for the federal government? Eventually one would assume there’s still going to be a federal government to work for, and there may not be anybody who wants to do it. 

Roubein: Yeah, you saw various hiring authorities given to try and recruit scientists and other researchers who make a lot, lot more in the public health sector, and some of those were a part of the probationary workforce because they had been hired recently under those authorities. 

Rovner: Yeah, and now this is all sort of coming apart. Well, meanwhile, the cuts are continuing even faster than federal judges can rule against them. Last week, the administration said it would reduce the number of HHS regional offices from 10 to four. Considering these are where the department’s major fraud-fighting efforts take place, that doesn’t seem a very effective way of going after fraud and abuse in programs like Medicare and Medicaid. Those regional offices are also where lots of beneficiary protections come from, like inspections of nursing homes and Head Start facilities. How does this serve RFK Jr.’s Make America Healthy Again agenda? 

Karlin-Smith: I think it’s not clear that it does, right? You’re talking about, again, the Department of Government Efficiency has focused on efficiency, cost savings, and Medicare and Medicaid does a pretty good job of fighting fraud and making HHS OIG [Office of Inspector General], all those organizations, they collect a lot of money back. So when you lose people— 

Rovner: And of course the inspector general has also been laid off in all of this. 

Karlin-Smith: Right. It’s not clear to me, I think one of the things with that whole reorganization of their chief counsel is people are suggesting, again, this is sort of a power move of HHS wanting to get a little bit more control of the legal operations at the lower agencies, whether it’s NIH [the National Institutes of Health] or FDA and so forth. But, right, it’s reducing head count without really thinking about what people’s roles actually were and what you lose when you let them go. 

Rovner: Well, the Trump administration is also continuing to cut grants and contracts that seem like they’d be the kind of things that directly relate to Make America Healthy Again. Jessie, you’ve chosen one of those as your extra credit this week. Tell us about it. 

Hellmann: Yeah. So my story is from Stat [“NIH Cancels Funding for a Landmark Diabetes Study at a Time of Focus on Chronic Disease”], and it’s about a nationwide study that tracks patients with prediabetes and diabetes. And it was housed at Columbia University, which as we know has been the subject of some criticism from the Trump administration. They had lost about $400 million in grants because the administration didn’t like Columbia’s response to some of the protests that were on campus last year. But that has an effect on some research that really doesn’t have much to do with that, including a study that looked at diabetes over a really long period of time. 

So it was able to over decades result in 200 publications about prediabetes and diabetes, and led to some of the knowledge that we have now about the interventions for that. And the latest stage was going to focus on dementia and cognitive impairment, since some of the people that they’ve been following for years are now in their older ages. And now they have to put a stop to that. They don’t even have funding to analyze blood samples that they’ve done and the brain scans that they’ve collected. So it’s just another example of how what’s being done at the administration level is contradicting some of the goals that they say that they have. 

Rovner: Yeah, and it’s important to remember that Columbia’s funding is being cut not because they deemed this particular project to be not helpful but because they are, as you said, angry at Columbia for not cracking down more on pro-Palestinian protesters after Oct. 7. 

Well, meanwhile, people are bracing for still more cuts. The Wall Street Journal is reporting the administration plans to cut domestic AIDS-HIV programming on top of the cuts to the international PEPFAR [President’s Emergency Plan for AIDS Relief] program that was hammered as part of the USAID cancellation. Is fighting AIDS and HIV just way too George W. Bush for this administration? 

Hellmann: It’s interesting because President [Donald] Trump unveiled the Ending the HIV Epidemic initiative in his first term, and the goal was to end the epidemic in the United States. And so if they were talking about reducing some of that funding, or I know there were reports that maybe they would move the funding from CDC [the Centers for Disease Control and Prevention] to HRSA [the Health Resources and Services Administration], it’s very unclear at this point. Then it raises questions about whether it would undermine that effort. And there’s already actions that the Trump administration has done to undermine the initiative, like the attacks on trans people. They’ve canceled grants to researchers studying HIV. They have done a whole host of things. They canceled funding to HIV services organizations because they have “trans” in their programming or on their websites. So it’s already caused a lot of anxiety in this community. And yeah, it’s just a total turnaround from the first administration. 

Rovner: I know the Whitman-Walker clinic here in Washington, which has long been one of the premier AIDS-HIV clinics, had just huge layoffs. This is already happening, and as you point out, this was something that President Trump in his first term vowed to end AIDS-HIV in the U.S. So this is not one would think how one would go about that. 

Well, it’s not just the administration that’s working to constrict rights and services. A group of 17 states, led by Texas, of course, are suing to have Biden-era regulations concerning discrimination against trans people struck down, except as part of that suit, the states are asking that the entirety of Section 504 of the Rehabilitation Act be declared unconstitutional. Now, you may never have heard of Section 504, but it is a very big deal. It was the forerunner of the Americans With Disabilities Act, and it prevents discrimination on the basis of disability in all federally funded activities. It is literally a lifeline for millions of disabled people that enables them to live in the community rather than in institutions. Are we looking at an actual attempt to roll back basically all civil rights as part of this war on “woke” and DEI [diversity, equity, and inclusion] and trans people? 

Hellmann: The story is interesting, because it seems like some of the attorneys general are saying, That’s not our intent. But if you look at the court filings, it definitely seems like it is. And yeah, like you said, this is something that would just have a tremendous impact. And Medicaid coverage of home- and community-based services is one of those things that states are constantly struggling to pay for. You’re just continuing to see more and more people need these services. Some states have waiting lists, so— 

Rovner: I think most states have waiting lists. 

Hellmann: Yeah. It’s something, you have to really question what the intent is here. Even if people are saying, This isn’t our intent, it’s pretty black-and-white on paper in the court records, so— 

Rovner: Yeah, just to be clear, this was a Biden administration regulation, updating the rules for Section 504, that included reference to trans people. But in the process of trying to get that struck down, the court filings do, as you say, call for the entirety of Section 504 to be declared unconstitutional. This is obviously one of those court cases that’s still before the district court, so it’s a long way to go. But the entire disability community, certainly it has their attention. 

Well, we haven’t had any big abortion news the past couple of weeks, but that is changing. In Texas, a midwife and her associate have become the first people arrested under the state’s 2022 abortion ban. The details of the case are still pretty fuzzy, but if convicted, the midwife who reportedly worked as an OB-GYN doctor in her native Peru and served a mostly Spanish-speaking clientele, could be sentenced to up to 20 years in prison. So, obviously, be watching that one. Meanwhile, here in Washington, Hilary Perkins, a career lawyer chosen by FDA commissioner nominee Marty Makary to serve as the agency’s general counsel, resigned less than two days into her new position after complaints from Missouri Sen. Josh Hawley that she defended the Biden administration’s position on the abortion pill mifepristone. 

Now, Hilary Perkins is no liberal trying to hide out in the bureaucracy. She’s a self-described pro-life Christian conservative hired in the first Trump administration, but she was apparently forced out for the high crime of doing her job as a career lawyer. Is this administration really going to try to evict anyone who ever supported a Biden position? Will that leave anybody left? 

Roubein: I think what’s notable is Sen. Josh Hawley here, who expressed concerns and I had heard expressed concerns to the White House, and the post on X from the FDA came an hour before the hearing. There were concerns that he was not going to make it out of committee and— 

Rovner: Before the Marty Makary hearing. 

Roubein: Yes, sorry, before the vote in the HELP [Health, Education, Labor and Pensions] Committee on Marty Makary. And Hawley said because of that, he would vote to support him. What was interesting is two Democrats actually ended up supporting him, so he could have passed without Hawley’s vote. But I think in general it poses a test for Marty Makary when he’s an FDA commissioner, and how and whether he’s going to get his people in and how he’ll respond to different pressure points in Congress and with HHS and with the White House. 

Rovner: And of course, Hawley’s not a disinterested bystander here, right? 

Karlin-Smith: So his wife was one of the key attorneys in the recent big Supreme Court case that was pushed down to the lower courts for a lack of standing, but she was trying to essentially get tighter controls on the abortion pill mifepristone. But it seems like almost maybe Hawley jumped too soon before doing all of his research or fully understanding the role of people at Justice. Because even before this whole controversy erupted, I had talked to people the day before about this and asked them, “Should we read into this, her being involved in this?” And everybody I talked to, including, I think, a lot of people that have different views than Perkins does on the case, that they were saying she was in a role as a career attorney. You do what your boss, what the administration, wants. 

If you really, really had a big moral problem with that, you can quit your job. But it’s perfectly normal for an attorney in that kind of position to defend a client’s interest and then have another client and maybe have to defend them wrongly. So it seems like if they had just maybe even picked up the phone and had a conversation with her, the whole crisis could have been averted. And she was on CNN yesterday trying to plead her case and, again, emphasize her positions because perhaps she’s worried about her future career prospects, I guess, over this debacle. 

Rovner: Yeah, now she’s going to be blackballed by both sides for having done her job, basically. Anyway, all right, well, one big Biden initiative that looks like it will continue is the Medicare Drug Price Negotiation program. And we think we know this because CMS announced last week that the makers of all of the 15 drugs selected for the second round of negotiations have agreed to, well, negotiate. Sarah, this is news, right? Because we were wondering whether this was really going to go forward. 

Karlin-Smith: Yeah, they’ve made some other signals since taking over that they were going to keep going with this, including last week at his confirmation hearing, Dr. Oz, for CMS, also indicated he seemed like he would uphold that law and they were looking for ways to lower drug costs. So I think what people are going to be watching for is whether they yield around the edges in terms of tweaks the industry wants to the law, or is there something about the prices they actually negotiate that signal they’re not really trying to get them as low as they can go? But this seems to be one populist issue for Trump that he wants to keep leaning into and keep the same consistency, I think, from his first administration, where he always took a pretty hard line on the drug industry and drug pricing. 

Rovner: And I know Ozempic is on that list of 15 drugs, but the administration hasn’t said yet. I assume that’s Ozempic for its original purpose in treating diabetes. This administration hasn’t said yet whether they’ll continue the Biden declaration that these drugs could be available for people for weight loss, right? 

Karlin-Smith: Correct. And I think that’s going to be more complicated because that’s so costly. So negotiating the price of drugs saves money. So yes, basically because Ozempic and Wegovy are the same drug, that price should be available regardless of the indication. But I’m more skeptical that they continue that policy, because of the cost and also just because, again, HHS Secretary Robert F. Kennedy seems to be particularly skeptical of the drugs, or at least using that as a first line of defense, widespread use, reliance on that. He tends to, in general, I think, support other ways of medical, I guess, treatment or health treatments before turning to pharmaceuticals. 

Rovner: Eating better and exercising. 

Karlin-Smith: Correct, right. So I think that’s going to be a hard sell for them because it’s just so costly. 

Rovner: We will see. All right, that is as much news as we have time for this week. Now, it is time for our extra-credit segment, that’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will put the links in our show notes on your phone or other mobile device. Jessie, you’ve done yours already this week. Rachel, why don’t you go next? 

Roubein: My extra credit, the headline is “Her Research Grant Mentioned ‘Hesitancy.’ Now Her Funding Is Gone.” In The Washington Post by my colleague Carolyn Y. Johnson. And I thought the story was particularly interesting because it really dove into the personal level. You hear about all these cuts from a high level, but you don’t always really know what it means and how it came about. So the backstory is the National Institutes of Health terminated dozens of research grants that focused on why some people are hesitant to accept vaccines. 

And Carolyn profiled one researcher, Nisha Acharya, but there was a twist, and the twist was she doesn’t actually study how to combat vaccine hesitancy or ways to increase vaccine uptake. Instead, she studies how well the shingles vaccine works to prevent the infection, with a focus on whether the shot also prevents the virus from affecting people’s eyes. But in the summary of her project, she had used the word “hesitancy” once and used the word “uptake” once. And so this highlights the sweeping approach to halting some of these vaccine hesitancy research grants. 

Rovner: Yeah that was like the DOD [Department of Defense] getting rid of the picture of the Enola Gay, the plane that dropped the atomic bomb, because it had the word “Gay” in it. This is the downside, I guess, of using AI for these sorts of things. Sarah. 

Karlin-Smith: I took a look at a KFF story by Arthur Allen, “Scientists Say NIH Officials Told Them to Scrub mRNA References on Grants,” and it’s about NIH officials urging people to remove any reference to mRNA vaccine technology from their grants. And the story indicates it’s not yet clear if that is going to translate to defunding of such research, but the implications are quite vast. I think most people probably remember the mRNA vaccine technology is really what helped many of us survive the covid pandemic and is credited with saving millions of lives, but the technology promise seems vast even beyond infectious diseases, and there’s a lot of hope for it in cancer. 

And so this has a lot of people worried. It’s not particularly surprising, I guess, because again, the anti-vaccine movement, which Kennedy has been a leader of, has been particularly skeptical of the mRNA technology. But it is problematic, I think, for research. And we spent a lot of time on this call talking about the decimation of the federal workforce that may happen here, and I think this story and some of the other things we talked about today also show how we may just decimate our entire scientific research infrastructure and workforce in the U.S. outside of just the federal government, because so much of it is funded by NIH, and the decisions they’re making are going to make it impossible for a lot of scientists to do their job. 

Rovner: Yeah, we’re also seeing scientists going to other countries, but that’s for another time. Well, my extra credit this week, probably along the same lines, also from The Washington Post. It’s part of a series called “Who Is Government?” This particular piece [“The Free-Living Bureaucrat”] is by bestselling author Michael Lewis, and it’s a sprawling — and I mean sprawling — story of how a mid-level FDA employee who wanted to help find new treatments for rare diseases ended up not only figuring out a cure for a child who was dying of a rare brain amoeba but managed to obtain the drug for the family in time to save her. It’s a really good piece, and it’s a really excellent series that tells the stories of mostly faceless bureaucrats who actually are working to try to make the country a better place. 

OK, that’s this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our producer, Francis Ying, and our editor, Emmarie Huetteman. As always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me at X, @jrovner, and at Bluesky, @julierovner. Where are you guys these days? Sarah? 

Karlin-Smith: A little bit everywhere. X, Bluesky, LinkedIn — @SarahKarlin or @sarahkarlin-smith. 

Rovner: Jessie. 

Hellmann: I’m @jessiehellmann on X and Bluesky, and I’m also on LinkedIn more these days. 

Rovner: Great. Rachel. 

Roubein: @rachelroubein at Bluesky, @rachel_roubein on X, and also on LinkedIn. 

Rovner: We will be back in your feed next week. Until then, be healthy. 

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

Mary Agnes Carey
KFF Health News

@maryagnescarey

Read Mary Agnes' stories

Partnerships Editor and Senior Correspondent, oversees placement of KFF Health News content in publications nationwide and covers health reform and federal health policy. Before joining KFF Health News, Mary Agnes was associate editor of CQ HealthBeat, Capitol Hill Bureau Chief for Congressional Quarterly, and a reporter with Dow Jones Newswires. A frequent radio and television commentator, she has appeared on CNN, C-SPAN, the PBS NewsHour, and on NPR affiliates nationwide. Her stories have appeared in The Washington Post, USA Today, TheAtlantic.com, Time.com, Money.com, and The Daily Beast, among other publications. She worked for newspapers in Connecticut and Pennsylvania, and has a master’s degree in journalism from Columbia University.

In most states, open enrollment for plans on the Affordable Care Act exchange — also known as Obamacare — began Nov. 1 and lasts until Dec. 15, though some states go longer. With premiums expected to increase by a median of 6%, consumers who get their health coverage through the federal or state ACA marketplaces are encouraged to shop around. Because of enhanced subsidies and cost-sharing assistance, they might save money by switching plans.

Meanwhile, Ohio is yet again an election-year battleground state. A ballot issue that would provide constitutional protection to reproductive health decisions has become a flashpoint for misinformation and message testing.

This week’s panelists are Mary Agnes Carey of KFF Health News, Jessie Hellmann of CQ Roll Call, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Rachana Pradhan of KFF Health News.

Panelists

Jessie Hellmann
CQ Roll Call

@jessiehellmann

Read Jessie's stories

Joanne Kenen
Johns Hopkins Bloomberg School of Public Health and Politico

@JoanneKenen

Read Joanne's stories

Rachana Pradhan
KFF Health News

@rachanadpradhan

Read Rachana's stories

Among the takeaways from this week’s episode:

• Open enrollment for most plans on the Affordable Care Act exchange — also known as Obamacare — began Nov. 1 and lasts until Dec. 15, though enrollment lasts longer in some states. With premiums expected to increase by a median of 6%, consumers are advised to shop around. Enhanced subsidies are still in place post-pandemic, and enhanced cost-sharing assistance is available to those who qualify. Many people who have lost health coverage may be eligible for subsidies.
• In Ohio, voters will consider a ballot issue that would protect abortion rights under the state constitution. This closely watched contest is viewed by anti-abortion advocates as a testing ground for messaging on the issue. Abortion is also key in other races, such as for Pennsylvania’s Supreme Court and Virginia’s state assembly, where the entire legislature is up for election.
• Earlier this week, President Joe Biden issued an executive order that calls on federal agencies, including the Department of Health and Human Services, to step into the artificial intelligence arena. AI is a buzzword at every health care conference or panel these days, and the technologies are already in use in health care, with insurers using AI to help make coverage decisions. There is also the recurring question, after many hearings and much discussion: Why hasn’t Congress acted to regulate AI yet?
• Our health care system — in particular the doctors, nurses, and other medical personnel — hasn’t recovered from the pandemic. Workers are still burned out, and some have participated in work stoppages to make the point that they can’t take much more. Will this be the next area for organized labor, fresh from successful strikes against automakers, to grow union membership? Take pharmacy workers, for instance, who are beginning to stage walkouts to push for improvements.
• And, of course, for the next installment of the new podcast feature, “This Week in Medical Misinformation:” The official government website of the Republican-controlled Ohio Senate is attacking the proposed abortion amendment in what some experts have said is a highly unusual and misleading manner. Headlines on its “On The Record” blog include “Abortion Is Killing the Black Community” and say the ballot measure would cause “unimaginable atrocities.” The Associated Press termed the blog’s language “inflammatory.”

Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:

Mary Agnes Carey: Stat News’ “The Health Care Issue Democrats Can’t Solve: Hospital Reform,” by Rachel Cohrs.

Jessie Hellmann: The Washington Post’s “Drugstore Closures Are Leaving Millions Without Easy Access to a Pharmacy,” by Aaron Gregg and Jaclyn Peiser.

Joanne Kenen: The Washington Post’s “Older Americans Are Dominating Like Never Before, but What Comes Next?” by Marc Fisher.

Rachana Pradhan: The New York Times’ “How a Lucrative Surgery Took Off Online and Disfigured Patients,” by Sarah Kliff and Katie Thomas.

Click to open the Transcript

Transcript: For ACA Plans, It’s Time to Shop Around

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]

Mary Agnes Carey: Hello, and welcome back to “What the Health?” I’m Mary Agnes Carey, partnerships editor for KFF Health News, filling in this week for Julie Rovner. I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Nov. 2, at 10 a.m. ET. As always, news happens fast, and things might’ve changed by the time you hear this.

We are joined today via video conference by Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.

Joanne Kenen: Hi, everybody.

Carey: Jessie Hellmann, of CQ Roll Call.

Jessie Hellmann: Hey there.

Carey: And my KFF Health News colleague Rachana Pradhan.

Rachana Pradhan: Thanks for having me.

Carey: It’s great to have you here. It’s great to have all of you here. Let’s start today with the Affordable Care Act. If you’re interested in enrolling in an ACA plan for coverage that begins Jan. 1, it’s time for you to sign up. The ACA’s open enrollment period began Nov. 1 and lasts through Dec. 15 for plans offered on the federal exchange, but some state-based ACA exchanges have longer enrollment periods. Consumers can go online, call an 800 number, get help from an insurance broker or from other ACA navigators and others who are trained to help you research your coverage options, help you find out if you qualify for a subsidy, or if you should consider changing your ACA plan.

What can consumers expect this year during open enrollment? Are there more or fewer choices? Are premiums increasing?

Hellmann: So, I saw the average premium will increase about 6%. So people are definitely going to want to shop around and might not necessarily just want to stick with the same plan that they had last year. And we’re also going to continue seeing the enhanced premiums, subsidies, that Congress passed last year that they kind of stuck with after the pandemic. So subsidies might be more affordable for people — I’m sorry, premiums might be more affordable for people. There’s also some enhanced cost-sharing assistance.

Carey: So it kind of underscores the idea that if you’re on the ACA exchange, you really should go back and take a look, right? Because there might be a different deal out there waiting.

Kenen: I think the wrinkle — this may be what you were just about to ask — but the wrinkle this year is the Medicaid disenroll, the unwinding. There are approximately 10 million, 10 million people, who’ve been disenrolled from Medicaid. Many of them are eligible for Medicaid, and at some point hopefully they’ll figure out how to get them back on. But some of those who are no longer eligible for Medicaid will probably be eligible for heavily subsidized ACA plans if they understand that and go look for it.

This population has been hard to reach and hard to communicate with for a number of reasons, some caused by the health system, not the people, or the Medicaid system, the states. They do have a fallback; they have some extra options. But a lot of those people should click and see what they’re eligible for.

Pradhan: One thing, kind of piggybacking on what Joanne said, that I’m really interested in: Of course, right now is a time when people can actively sign up for ACA plans. But the people who lost Medicaid, or are losing Medicaid — technically, the state Medicaid agency, if they think that a person might qualify for an ACA plan, they’re supposed to automatically transfer those people’s applications to their marketplace, whether it’s healthcare.gov or a state-based exchange. But the data we have so far shows really low enrollment rates into ACA plans from those batches of people that are being automatically transferred. So I’m really curious about whether that’s going to improve and what does enrollment look like in a few months to see if those rates actually increase.

Carey: I’m also wondering what you’re all picking up on the issue of the provider networks. How many doctors and hospitals and other providers are included in these plans? Are they likely to be smaller for 2024? Are they getting bigger? Is there a particular trend you can point to?

I know that sometimes insurers might reduce the number of providers, narrow that network, for example to lower costs. So I guess that remains to be seen here.

Kenen: I haven’t seen data on the ACA plans, and maybe one of the other podcasters has. I haven’t seen that. But we do know that in certain cities, including the one we all live in [Washington, D.C.], many doctors are stopping, are no longer taking insurance. I mean, it’s not most, but the number of people who are dropping being in-network in some of the major networks that we are used to, I think we have all encountered that in our own lives and our friends’ and families’ lives. There are doctors opting out, or they’re in but their practices are closed; they’re not taking more patients, they’re full.

I don’t want to pretend I know how much worse it is or isn’t in ACA plans, but we do know that this is a trend for multiple years. In some parts of the country, it’s getting worse.

Hellmann: Yeah, the Biden administration has been doing some stuff to try to address some of these problems. Last year there were some rules requiring health plans have enough in-network providers that meet specific driving time and distance requirements. So, they are trying to address this, but I wouldn’t be surprised if some of these plans’ networks are still pretty narrow.

Pradhan: Yeah. I mean, I think the concern for a while now with ACA plans is because insurance companies can’t do the things that they did a decade ago to limit premium increases, etc., one of the ways they can keep their costs down is to curtail the number of available providers for someone who signs up for one of these plans. So, like Jessie, I’m curious about how those new rules from last year will affect whether people see meaningful differences in the availability of in-network providers under specific plans.

Carey: That and many other trends are worth watching as we head into the open enrollment season. But right now, I’d like to turn to another topic in the news, and that’s abortion. “What the Health?” listeners know that last week your host, Julie Rovner, created a new segment that she’s calling “This Week in Health Care Misinformation.” Here’s this week’s entry.

A measure before Ohio voters next Tuesday, that’s Nov. 7, would amend Ohio’s constitution to guarantee the right to reproductive health care decisions, including abortion. Abortion rights opponents say the measure is crafted too broadly and should not be approved. The official government website of the Republican-controlled Ohio Senate is attacking the proposed abortion amendment in what some experts have said is a highly unusual and misleading manner. Headlines on the “On The Record” blog — and that’s what it’s called, “On The Record”; this is on the Ohio state website — it makes several claims about the measure that legal and medical experts have told The Associated Press were false or misleading. Headlines on this site include, and I’m quoting here, “Abortion Is Killing the Black Community” and that the proposal would cause, again, another quote, “unimaginable atrocities.” Isn’t it unusual for an official government website to operate in this manner?

Pradhan: I think yes, as far as we know, and that’s really scary. It’s hard enough these days to sort out what is legitimate and what isn’t. We’ve seen AI [artificial intelligence] used in other political campaign materials in the forms of altered videos, photographs, etc. But now this is a really terrifying prospect, I think, that you could provide misinformation to voters — particularly in close races, I would say, that you could really swing an outcome based on what people are being told.

Kenen: The other thing that’s being said in Ohio by the Republicans is that the measure would allow, quote, “partial-birth abortions,” which is a particular — it’s a phrase used to describe a particular type of late-term abortion that’s illegal. Congress passed legislation, I think it’s 15 to 20 years ago now, and it went through the courts and it’s been upheld by the courts. This measure in Ohio does not undo federal law in the state of Ohio or anywhere else. So that’s not true. And that’s another thing circulating.

Carey: This discussion is very important. And to Rachana’s point, how voters perceive this is very important because Ohio is serving as a testing ground for political messaging headed into the presidential race next year. And abortion groups are trying to qualify initiatives in more states in 2024, potentially including Arizona. So even if you haven’t followed this story closely, I mean, how do you think this tactic may influence voters? Again, you’re talking about something — when you hit a news tab on an official state website, you come to this blog. Do you think voters will reject it? Could it possibly influence them — as you were talking about earlier, tip the results?

Kenen: Well, I don’t think we know how it’s going to tip, because I don’t know how many people actually read the state legislature blog.

Carey: Yeah, that could be an issue.

Kenen: Although, and the coverage of it, one would hope, in the state media would point out that some of these claims are untrue. But I mean, it’s taking — you know, the Republicans have lost every single state ballot initiative on abortion, and it’s been a winning issue for the Democrats and they’re trying to reframe it a little bit, because while polls have shown — not just polls, but voting behavior has shown — many Americans want abortion to remain legal, they aren’t as comfortable with late-term abortions, with abortions in the final weeks or months of pregnancy. So this is trying to shift it from a general debate over banning abortion, which is not popular in the U.S., to an area where there’s softer support for abortions later during pregnancy.

And polls have shown really strong support for abortion rights. But this is an area that is not as strong, or a little bit more open to maybe moving people. And if the Republicans succeed in portraying this as falsely allowing a procedure that the country has decided to ban, I think that’s part of what’s going on, is to shift the definition, shift the terms of debate.

Carey: As we know, Ohio is not the only state where abortion is taking center stage. For example, in Pennsylvania, abortion is a key issue in the state Supreme Court justice election, and it’s a test case of political fallout from the Supreme Court, the United States Supreme Court’s decision last summer to overrule Roe v. Wade. In Texas, the state is accusing Planned Parenthood of defrauding the Republican-led state’s Medicaid health insurance program. And in Kansas, in a victory for abortion rights advocates, a judge put a new state law on medication abortions on hold and blocked other restrictions governing the use and distribution of these medications and imposed waiting periods.

And of course, abortion remains a huge issue on Capitol Hill, with House Republicans inserting language into many spending bills to restrict abortion access, to block funding for HIV prevention, contraception, global health programs, and so on. So, which of these cases, or others maybe that you are watching, do you think will be the strongest indicators of how the abortion battle will shake out for the rest of this year and into 2024?

Pradhan: I’m actually going to make a plug for another one that we didn’t mention, which is for our local, D.C.-area listeners, Virginia next week has a state legislative election. So, Gov. [Glenn] Youngkin of course is still — he’s not up for reelection; he’ll sit one single four-year term, but the entire Virginia General Assembly is up for election. So currently Gov. Youngkin says that he wants to institute a 15-week abortion ban, but Republicans would need to control every branch of government, which they do not currently, but it is possible that they will after next week. So that would be a big change as you see abortion restrictions that have proliferated, especially throughout the South and the Midwest. But now Virginia so far has not, in the wake of last year’s Dobbs [v. Jackson Women’s Health Organization] decision, has not imposed greater restrictions on access to abortion.

But I think the 15-week limit also provides kind of a test case, I think, for whether Republicans might be able to coalesce around that standard as opposed to something more aggressive like, say, a total ban or a six-week ban that’s obviously been instituted in certain states but I think at a national level right now is a nonstarter. I’m pretty interested in seeing what happens even in a lot of our own backyard.

Kenen: Because Virginia’s really tightly divided. I mean, the last few elections. This was a traditional Republican state that has become a purple state. And the last few state legislature elections, didn’t they once decide by drawing lots? It was so close. I mean it’s flipped back. It’s really, really, really tiny margins in both houses. I think Rachana lives there and knows the details better than I do. But it’s razor-thin, and it was Republican-controlled for a long time and Democrats, what, have one-seat-in-the-Senate control? Something like that, a very narrow margin. And they may or may not keep it.

Pradhan: Joanne, your memory’s so good, because they had —

Kenen: Because I edited your stories.

Pradhan: You did. I know. And they had to draw names out of a bowl that was— it was in a museum. It was something that a Virginia potter had made and they had to take it out of a museum exhibit. I mean, it was the most — it’s really fascinating what democracy can look like in this country when it comes down to it. It was such a bizarre situation to decide control of the state House. So you’re very right, so it’s very close.

Kenen: It’s also worth pointing out, as we have in prior weeks, that 15 weeks is now being offered as this sort of moderate position, when 15 weeks — a year ago, that’s what the Supreme Court case was really about, the case we know as Dobbs. It was about a law in Mississippi that was a 15-week ban. And what happened is once the courts gave the states the go-ahead, they went way further than 15 weeks. I don’t know how many states have a 15-week ban, not many. The anti-abortion states now have sort of six weeks-ish or less. North Carolina has 12, with some conditions. So 15 weeks is now Youngkin saying, “Here’s the middle ground.” I mean, even when Congress was trying to do a ban, it was 20, so — when they had those symbolic votes, I think it was always 20. He’s changed the parameters of what we’re talking about politically.

Carey: Jessie, how do you see the abortion riders on these appropriations bills, particularly in the House. House Republicans have put a lot of this abortion language into the approps bills. How do you see that shaking out, resolving itself, as we look forward?

Hellmann: It is hard to see how some of these riders could become law, like the one in the FDA-Ag approps bill that would basically ban mailing of mifepristone, which can be used for abortions. Even some moderate Republicans who are really against that rider — I mean just a handful, but it’s enough where it should just be a nonstarter. So I’m just not sure how I can see a compromise on that right now. And I definitely don’t see how that could pass the Senate. So it’s just everything has become so much more contentious since the Roe decision. And things that weren’t contentious before, like the PEPFAR [The United States President’s Emergency Plan for AIDS Relief] reauthorization, are now being bogged down in abortion politics. It’s hard to see how the two sides can come to an agreement at this point.

Carey: Yes, contentious issues are everywhere. So, let’s switch from abortion to AI. Earlier this week, President Biden issued an executive order that calls on several federal agencies, including the Department of Health and Human Services, to create regulations governing the use of AI, including in health care. What uses of AI now in health care, or even future uses, are causing the greatest concern and might be the greatest focus of this executive order? And I’m thinking of things that work well in AI or are accepted, and things that maybe aren’t accepted at this point or people are concerned about.

Kenen: I think that none of us on the panel are super AI experts.

Carey: Nor am I, nor am I.

Kenen: But we are all following it and learning about it the way everybody else is. I think this is something that Vice President Harris pointed out in a summit in London on AI yesterday. There’s a lot of focus on the existential, cosmic scary stuff, like: Is it going to kill us all? But there’s also practical things right now, particularly in health care, like using algorithms to deny people care. And there’s been some exposés of insurance doing batch denials based on an AI formula. There’s concerns about — since AI is based on the data we have and the data, that’s the foundation, that’s the edifice. So the data we have is flawed, there’s racial bias in the data we have. So how do you make sure the algorithms in the future don’t bake in the inequities we already have? And there’s questions too about AI is already being used clinically, and how well does it really work? How reliable are the studies and the data? What do we know or not know before we start?

I mean, it has huge potential. There are risks, but it also has huge potential. So how do we make sure that we don’t have exaggerated happy-go-lucky mistrust in technology before we actually understand what it can and cannot do and what kind of safeguards the government —and the European governments as well; it’s not just us, and they may do a better job — are going to be in place so that we have the good without … The goal is sort of, to be really simplistic about it, is let’s have the good without the bad, but doing it is challenging.

Carey: Oh, Rachana, please.

Pradhan: Well, all I was going to say was nowadays you cannot go to a health care conference or a panel discussion without there being some session about AI. I guess it demonstrates the level of interest. It kind of reminds me of every few years there’s a new health care unicorn. So there was ACOs [accountable care organizations] for a long time; that’s all people would talk about. Or value-based care, like every conference you went to. And then with covid, and for other reasons, everyone is really big on equity, equity, equity for a long time. And now it’s like AI is everywhere.

So like Joanne said, I mean, we have everything from a chatbot that pops up on your screen to answer even benign questions about insurance. That’s AI. It’s a form of AI. It’s not generative AI, but it is. And yeah, I mean, insurance companies use all sorts of algorithms and data to make decisions about what claims they’re going to pay and not pay. So yeah, I think we all just have to exercise some skepticism when we’re trying to examine how this might be used for good or bad.

Kenen: I just want a robot to clean my kitchen. Why doesn’t anyone just handle the … Silicon Valley does the really important stuff.

Carey: That would be a use for good in your house, in my house, in all our houses.

Kenen: Yeah.

Carey: So, while we’re understandably and admittedly not AI experts, we are experts on Congress here. And the president did say in his announcement earlier this week that Congress still needs to act on this issue. Why haven’t they done it yet? They’ve had all these hearings and all this conversation about crafting rules around privacy, online safety, and emerging technologies. Why no action so far? And any bets on whether it may or may not happen in the near future?

Hellmann: I think they don’t know what to do. We’ve only, as a country, started really talking about AI at kitchen tables, to use a cliche, this year. And so Congress is always behind the eight ball on these issues. And even if they are having these member meetings and talking about it, I think it could take a long time for them to actually pass any meaningful legislation that isn’t just directing an agency to do a study or directing an agency to issue regulations or something that could have a really big impact.

Carey: Excellent. Thank you. So let’s touch briefly — before we wrap, I really do want to get to this point and some of the stuff we continue to see in the news about health care workers under fire. It’s certainly not easy to be a health care worker these days. New findings published by the Centers for Disease Control and Prevention show that, in 2022, 13.4% of health workers said they had been harassed at work. That’s up from 6.4% in 2018. That’s more than double the rate of workplace harassment compared to pre-pandemic times, the CDC found.

We’ve talked about this before. It’s worth revisiting again. What is going on with our health care workforce? And what do these kind of findings mean for keeping talented people in the workforce, attracting new people to join?

Hellmann: Has anyone actually caught a break after the pandemic?

Carey: That’s a good point.

Hellmann: I mean, covid is still out there, but I don’t think that our health care system has really recovered from that. People have left the workforce because they’re burned out. People still feel burned out who stuck around, and I don’t know if they really got any breaks or the support that they needed. There’s just kind of this recognition of people being burned out. But I don’t know how much action there is to address the issue.

I feel like sometimes that leads to more burnout, when you see executives and leaders acknowledging the problem but then not really doing much to address it.

Carey: Well, that’s certainly been the complaint by pharmacy staff and others and pharmacists at some of the large drugstore chains, retail chains, that have gone out on strike. They’ve had these two- and three-day strikes recently. So, I’m assuming that will continue, unfortunately, for all the reasons that Jessie just laid out.

Pradhan: Actually, kind of going back to the strikes from pharmacists, I was thinking about this earlier because we’ve seen recently, I think separately in the news when it comes to labor unions, and maybe this will have some bearing, maybe not, but the United Auto Workers strike — I mean, they extracted some of the largest concessions from automakers as far as pay increases. And people are seeing, they really got a victory after striking for weeks. And I think people, at least the coverage that I’ve seen has talked about how that union win might not just catalyze greater labor union involvement, not just in the auto industry but in other parts of the country and other sectors.

And so, I’m not sure what percentage of pharmacists are part of labor unions, but I think people have sort of said more recently that organized labor is having a moment, or has been, that it has not in a while. And so, I’ll be fascinated to see whether there’s a greater appetite among pharmacists to actually be part of a labor union and sort of whether that results in greater demands of some of these corporate chains. As we know — we can talk about this I think in a little bit — but the corporate chains have really taken over pharmacies in America, and rural pharmacies are really dying off. And so that has a lot of important implications for the country.

Kenen: I think the problems with the health care workforce are not all things that labor unions can address, because some of it is how many hours you work and what kind of shifts you have and how often they change and things that — yeah, I mean, labor is having a moment, Rachana’s right. But they’re also tied to larger demographic trends, with an aging society. It’s tied to, our whole system is geared toward the, like dean of nursing at [Johns] Hopkins Sarah Szanton is always talking about, it’s not so much not having enough nurses; we’ve got them in the wrong places. If we did more preventive care and community care and chronic disease management in the community, you wouldn’t have so many people in the hospital in the first place where the workforce crisis is.

So some of these larger issues of how do we have a better health care system; labor negotiations can address aspects of it. Nursing ratios are controversial, but that’s a labor issue. It’s a regulatory issue as well. But our whole system’s so screwed up now that Jessie’s right, nobody recovered from the strains of the pandemic in many sectors, probably all sectors of society, but obviously particularly brutal on the health care workforce. We didn’t get to hit pause and say, OK, nobody get sick for six months while we all recover. The unmet psychiatric needs. I mean, it’s just tons of stuff is wrong, and it’s manifesting itself in a workforce crisis. So maybe if you don’t have anyone to take care of you, maybe people will pay attention to the larger underlying reasons for that.

Carey: That’s an issue I’m sure we will talk more about in the future because it’s just not going anywhere. But for now, we’re going to turn to our extra credit segment. That’s when we each recommend a story we read this week and think you should read, too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device.

Joanne, why don’t you go first this week?

Kenen: Well, speaking of which, after we just talked about, there’s a piece in The Washington Post by Marc Fisher. It has a long headline: “Older Americans Are Dominating Like Never Before, but What Comes Next?” And basically it’s talking about not so much the nursing and physician workforce, although that’s part of it, just the workforce in general. We have more people working longer, and in areas where there’s shortages, there’s nothing wrong with having old people. A lot of communities have shortages of school bus drivers. So if you have a lot of older school bus drivers and they’re safe and like kids and like driving the bus, more power to them. If you’re 55 and you can drive a school bus full of nine-year-olds, middle schoolers, so much more.

Carey: Good luck with that one.

Kenen: But some of the physician specialties — one of the people in the story is a palliative care physician who retired and isn’t happy retired and wants to go back to work. And that’s another area where we need more people. But it’s a cultural shift, like, who’s doing what when, and how does it affect the younger generation? Although there was a reference to Angelina Jolie being on the old side at 48. I guess for an actress that might be old. But that wasn’t the gist of it. But we have this shift toward older people in many places, not just Trump and Biden. It’s sort of the whole workforce.

Carey: Got it. Jessie.

Hellmann: My extra credit is also a story from The Washington Post. It’s called “Drugstore Closures Are Leaving Millions Without Easy Access to a Pharmacy.” Focused specifically on some of the big national chains like CVS and Walgreens and Rite Aid, which have really kind of dominated the drugstore space over the past few decades. But now they are dealing with the repercussions from all these lawsuits that are being filed alleging they had a role in the opioid epidemic. And the story just kind of looks at the consequences of that.

These aren’t just places people get prescriptions. They rely on them for food, for medical advice, especially in rural and underserved areas. So yeah, I just thought it was a really interesting look at that issue.

Carey: Rachana?

Pradhan: So my extra credit is a story in The New York Times called “How a Lucrative Surgery Took Off Online and Disfigured Patients.” It’s horrifying. It’s a story about surgeons who are performing a complex type of hernia surgery and evidently are learning their techniques, or at least a large share of them are learning their techniques, by watching videos on social media. And the techniques that are demonstrated there are not exactly high quality. So the story digs into resulting harm to patients.

Kenen: And it’s unnecessary surgery in the first place — for many, not all. But it’s a more complicated procedure than they even need in a large portion of these patients.

Carey: My extra credit is written by Rachel Cohrs of Stat, and she’s a frequent guest on this program. Her story is called “The Health Care Issue Democrats Can’t Solve: Hospital Reform.” While Democrats have seized on lowering health care costs as a politically winning issue — they’ve taken on insurers and the drug industry, for example — Rachel writes that hospitals may be a health care giant they’re unable to confront alone, and they being the Democrats. As we know, hospitals are major employers in many congressional districts. There’s been a lot of consolidation in the industry in recent years. And hospital industry lobbyists have worked hard to preserve the image that they are the good guys in the health care industry, Rachel writes, while others, like pharma, are not.

Well, that’s our show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps others find us too. Special thanks, as always, to our engineer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you could still find me on X. I am @maryagnescarey. Rachana?

Pradhan: I am @rachanadpradhan on X.

Carey: Jessie.

Hellmann: @jessiehellmann.

Carey: And Joanne.

Kenen: I’m occasionally on X, @JoanneKenen, and I’m trying to get more on Threads, @joannekenen1.

Carey: We’ll be back in your feed next week, and until then, be healthy.

Credits

Francis Ying
Audio producer

Stephanie Stapleton
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

This week, while KFF Health News’ “What the Health?” takes a break, here’s an encore of a favorite episode this year: Host and chief Washington correspondent Julie Rovner leads a rare conversation with the current and two former secretaries of Health and Human Services. Taped in June before a live audience at Aspen Ideas: Health, part of the Aspen Ideas Festival, in Aspen, Colorado, Secretary Xavier Becerra and two of his predecessors, Kathleen Sebelius and Alex Azar, talk candidly about what it takes to run a department with more than 80,000 employees and a budget larger than those of many countries.

Among the takeaways from this week’s episode, originally aired in June:

• The Department of Health and Human Services is much more than a domestic agency. It also plays a key role in national security, the three HHS secretaries explained, describing the importance of the “soft diplomacy” of building and supporting health systems abroad.
• Each HHS secretary — Sebelius, who served under former President Barack Obama; Azar, who served under former President Donald Trump; and Becerra, the current secretary, under President Joe Biden — offered frank, sobering, and even funny stories about interacting with the White House. “Anything you thought you were going to do during the day often got blown up by the White House,” Sebelius said. Asked what he was unprepared for when he started the job, Azar quipped: “The Trump administration.”
• Identifying their proudest accomplishments as the nation’s top health official, Azar and Becerra both cited their work responding to the covid-19 pandemic, specifically Operation Warp Speed, the interagency effort to develop and disseminate vaccines, and H-CORE, which Becerra described as a quiet successor to Warp Speed. They also each touted their respective administrations’ efforts to regulate tobacco.
• Having weathered recent debates over the separation of public policy and politics at the top health agency, the panel discussed how they’ve approached balancing the two in decision-making. For Becerra, the answer was unequivocal: “We use the facts and the science. We don’t do politics.”

Click to open the transcript

Transcript: An Encore: 3 HHS Secretaries on What the Job Is Really Like

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello “What the Health?” listeners. We’re taking this week off from the news while KFF holds an all-staff retreat. We’ll be back next week, but in the meantime, here’s an encore of one of our favorite episodes of the year — a chat with three Health and Human Services Secretaries. We’ll be back next week with our regular news roundup.

Hello and welcome back to “What the Health?” I’m Julie Rovner, coming to you this week from the Aspen Ideas: Health conference in Aspen, Colorado. We have a cool special for you this week. For the first time, the current secretary of Health and Human Services sat down for a joint interview with two of his predecessors. This was taped before a live audience on Wednesday evening, June 21, in Aspen. So, as we like to say, here we go.

Hello. Good evening. Welcome to Aspen Ideas: Health. I’m Julie Rovner. I’m the chief Washington correspondent for KFF Health News and also host of KFF Health News’ health policy podcast, “What the Health?,” which you are now all the audience for, so thank you very much. I’m sure these people with me need no introduction, but I’m going to introduce them anyway because I think that’s required.

Immediately to my left, we are honored to welcome the current U.S. secretary of Health and Human Services, Xavier Becerra. Secretary Becerra is the first Latino to serve in this post. He was previously attorney general of the state of California. And before that, he served in the U.S. House of Representatives for nearly 25 years, where, as a member of the powerful Ways and Means Committee, he helped draft and pass what’s now the Affordable Care Act. Thank you for joining us.

Next to him, we have Kathleen Sebelius, who served as secretary during the Obama administration from 2009 to 2014, where she also helped pass and implement the Affordable Care Act. I first met Secretary Sebelius when she was Kansas’ state insurance commissioner, a post she was elected to twice. She went on to be elected twice as governor of the state, which is no small feat in a very red state for a Democrat. Today, she also consults on health policy and serves on several boards, including — full disclosure — that of my organization, KFF. Thank you so much for being here.

And on the end we have Alex Azar, who served as HHS secretary from 2018 to 2021 and had the decidedly mixed privilege of leading the department through the first two years of the covid pandemic, which I’m sure was not on his to-do list when he took the job. At least Secretary Azar came to the job with plenty of relevant experience. He’d served in the department previously as HHS deputy secretary and as general counsel during the George W. Bush administration and later as a top executive at U.S. drugmaker Eli Lilly. Today, he advises a health investment firm, teaches at the University of Miami Herbert Business School, and sits on several boards, including the Aspen Institute’s. So, thank you.

Former Secretary of Health and Human Services Alex Azar: Thank you.

Rovner: So I know you’re not here to listen to me, so we’re going to jump in with our first question. As I’m sure we will talk about in more detail, HHS is a vast agency that includes, just on the health side, agencies including the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services. The department has more than 80,000 employees around the country and throughout the world and oversees more than one and a half trillion dollars of federal funding each year. I want to ask each of you — I guess we’ll start with you — what is the one thing you wish the public understood about the department that you think they don’t really now?

Secretary of Health and Human Services Xavier Becerra: Given everything you just said, I wish people would understand that the Constitution left health care to the states. And so, as big as we are and as much as we do — Medicare, Medicaid, CHIP [Children’s Health Insurance Program], Obamacare — we still don’t control or drive health care. The only way we get in the game is when we put money into it. And that’s why people do Medicare, because we put money into it. States do Medicaid because we put money into it. And it became very obvious with covid that the federal government doesn’t manage health care. We don’t have a national system of health or public health. We have a nationwide system of public health where 50 different states determine what happens, and so one state may do better than another, and we’re out there trying to make it work evenhandedly for everyone in America. But it’s very tough because we don’t have a national system of public health.

Rovner: Secretary, what’s the thing that you wish people understood about HHS?

Former Secretary of Health and Human Services Kathleen Sebelius: Well, I agree with what Secretary Becerra has said, but it always made me unhappy that people don’t understand fully, I don’t think, the international role that HHS plays, and it is so essential to the safety and security and resilience of the United States. So we have employees across the world. CDC has employees in about 40 other countries, and helping to build health systems in various parts of the world, sharing information about how you stand up a health system, what a great hospital looks like. NIH does experiments and clinical trials all over the globe and is regarded as the gold standard. And we actually, I think, at HHS were able to do what they call soft diplomacy. And a lot of countries aren’t eager to have the State Department involved. They’re certainly not eager to see soldiers. Our trade policies make some people uncomfortable. But they welcome health professionals. They welcome the opportunity to learn from the United States. So it’s really a way often to get into countries and make friendships. And we need to monitor across the globe, as covid showed so well. When an outbreak happens someplace else in the world, we can’t wait for it to arrive on the border of the United States. Safety and security of American citizens really depends on global information exchange, a global surveillance exchange. The CDC has also trained epidemiologists in regions around the world so that they can be faster and share information. And I think too often in Congress, those line items for foreign trips, for offices elsewhere, people say, “Well, we don’t really need that. We should focus all our attention on America.” But I’ve always thought, if folks really understood how integral it is not just to our health security, but really national security, that we have these partnerships — and it’s, as I say, I think the best soft diplomacy and the cheapest soft diplomacy underway is to send health professionals all over the globe and to make those friendships.

Rovner: Do you think people understand that better since covid?

Sebelius: Maybe. You know, but some people reacted, unfortunately, to covid, saying, “Well, we put up bigger walls, and we” — I mean, no disease needs a passport, no wall stops things from coming across our borders. And I’m not sure that still is something that people take to heart.

Rovner: Secretary Azar, you actually have the most — in terms of years — experience at the department. What is it that people don’t know that they should?

Azar: So I probably would have led with what Secretary Becerra said about just how highly decentralized the public health infrastructure and leadership and decision-making is in the United States. I mean, it really — all those calls are made, and it’s not even just the 50 states. It’s actually 62 public health jurisdictions, because we separately fund a whole series of cities. I’ll concur in that. I’d say the other thing that people probably don’t understand, and maybe this is too inside baseball, is the secretary of HHS is, on the one hand, probably the most powerful secretary in the Cabinet and, on the other hand, also quite weak. So literally every authority, almost every authority, in the thousands and thousands of pages of U.S. statute that empower programs at HHS, say, “The secretary shall …” So the FDA, the CDC, CMS, all of these programs really operate purely by delegation of the secretary, because Secretary Becerra allows them to make decisions or to run programs. They are his authorities. And so the media, then, when the secretary acts, will … [unintelligible] … “How dare you,” you know, “how dare you be involved in this issue or that issue?” Well, it is legally and constitutionally Secretary Becerra’s job. And, on the other hand, you are supervising — it’s like a university, because you’re also supervising operating divisions that are global household brands. It is really like being a university president, for all that’s good and evil of that. You have to lead by consensus. You have to lead by bringing people along. You are not a dictator, in spite of what the U.S. statutes say. It’s very, very similar to that — that you, the secretary, is both powerful, but also has to really lead a highly matrixed, consensus-based organization to get things done.

Rovner: You’re actually leading perfectly into my next question, which is, how do you juggle all the moving pieces of this department? Just putting the agency heads in one room could fill a room this size. So tell us what sort of an average day for each of you would look like as secretary, if there’s such a thing as an average day.

Azar: Well, first, not an average administration, so take with a grain of salt my average day. So, interspersed among the two to five phone calls with the president of the United States between 7 a.m. and midnight, you know, other than that, um — I started every day meeting with my — you know, as secretary, you’ve got to have a team around you that’s not just your operating divisions, but I would start every morning — we would have just a huddle with chief of staff, deputy chief of staff, my head of public affairs. Often my general counsel would join that, my legislative leader. Just what’s going to hit us in the face today? Like, what are we trying to do, and what’s going to hit us in the face today? Just a situational awareness, every morning at about 8 a.m., quick huddle on that, and then diving into really the rhythm of the day of — I tried to drive — I use a book that I helped actually do some of the work on called “The 4 Disciplines of Execution,” just a tool of how do you focus and drive change in very complex organizations? So I tried to focus on four key initiatives that I spent as much of my time as secretary on leading and pushing on, and so I tried to make sure as much of my time was doing that. But then it’s reactive. You’re having to go to White House meetings constantly. You have to sign off on every regulation at the department. And so you’re in meetings just getting briefed and deciding approve or disapprove, so that rhythm constantly, and then add travel in, add evening commitments, add speeches. I’d say the biggest challenge you have as a leader in HHS is that first point of, focus, because you could be like a bobber on the water, just going with whatever’s happening, if you don’t have a maniacally focused agenda of, “I’ve got a limited amount of time. I’m going to drive change here. And if I don’t spend time every day pushing the department on this issue, being basically a burr in the saddle to make it happen, it won’t.” And you’ve just got to constantly be on that.

Rovner: Secretary Sebelius, what did your average day look like?

Sebelius: Well, I’m not going to repeat what Alex has just said. A lot of that goes on in the daily routine. First of all, I think all of us would be sent home the night before with a binder of materials — briefings for what you’re going to do the next day. So you may have 10 meetings, but each of those has a 20-page brief behind it. And then what the issues are, what the questions might be. So that’s your homework often that you’re leaving with at 7 or 8 at night. I like to run in the morning, and I would get up, read my schedule, and then go out and run on the [National] Mall because it sort of cleared my head. I’m proud of having — some of the folks may still be here — none of the detail ran before I started running, and my deal with them was, “I’m much older than you are, you know. We’re all going to run.”

Azar: They still —

Sebelius: Oh, here we go.

Azar: They still talk about it.

Sebelius: Well, one of them got to be a great marathon runner, you know. Can’t hurt. One guy started riding a bike, and I was like, “What are you doing?” I mean, if I fall, what are you going to do with the bike? I mean, am I going to carry it, are you going to carry it? I mean, who — anyway, so I started that way. You’d go then into the office. And one of the things that was not mentioned is HHS has an amazing, camera-ready studio, TV studio, that lots of other Cabinet agencies used. It has a setting that looks like “The View.” It has a stool that you can look in cameras, but two or three days a week we would do what they call “Around the Country.” So you would sit in a stool, and I’d be doing updates on the ACA or a pitch to enrollment or something about a disease, and you would literally have a cue card up that would say “Minneapolis, Andrea.” And I would say, “Good morning, Andrea.” And we would do a two-second spot in Minneapolis and they’d have numbers for me and then the camera would switch and it would be Bob in St. Louis. “Hello, Bob. How are you?” So that was a morning start that’s a little bit different. Anything you thought you were going to do during the day often got blown up by the White House: somebody calling, saying, you know, “The president wants this meeting,” “the vice president’s calling this.” So then the day gets kind of rearranged. And I think the description of who the key staff are around, but 12 operating agencies — any one of them could be a much more than full-time job. So just getting to know the NIH or, you know, seeing what CDC in Atlanta does every day, but trying to keep the leadership in touch, in tune, and make sure that — one of the things that, having been a governor and working with Cabinet agencies, that I thought was really important, is everybody has some input on everything. These are the stars, the agency heads. They know much more about health and their agencies than I would ever know. But making sure that I have their input and their lens on every decision that was made. So we had regular meetings where the flatter the organization, the better, as far as I’m concerned. They were all there and they gave input into policy decisions. But it is not a boring job and it’s never done. You just had to say at the end of the day, with this giant book, “OK, that’s enough for today. I’ll start again tomorrow, and there’ll be another giant book and here we go.”

Rovner: And your day, since you’re doing it now?

Becerra: I don’t know if it’s the pleasure or the bane of starting off virtually. Almost everything we did was via Zoom. I didn’t meet many of my team until months into the term because we were in the midst of covid. So we would start the days usually pretty early in the morning with Zooms and it would go one Zoom after the other. Of course, once we started doing more in-person activities, schedulers still thought they could schedule you pretty much one right after the other, and so they pack in as much as they can. I think all of us would say we’re just blessed to have some of the most talented people. I see Commissioner Califf from the FDA over there in the room. I will tell you, it’s just a yes … [applause] … . It’s a blessing to get to serve with these folks. They are the best in their fields. And you’re talking about some pretty critical agencies, FDA, NIH, CDC, CMS. I mean, the breadth, the jurisdiction, of CMS is immense. They do fabulous work. They are so committed. And so it makes it a lot easier. And then, of course, we all — we each have had — I have my group of counselors who are essentially my captains of the different agencies, and they help manage, because without that it would be near-impossible. And these are people who are younger, but my God, they’re the folks that every CEO looks for to sort of help manage an agency, and they’re so committed to the task. And so I feel like a kid in a candy store because I’m doing some of the things that I worked on so long when I was a member of Congress and could never get over the finish line. Now I get to sort of nudge everything over the finish line, and it really is helpful, as Alex said, to remind people that the statute does say, “The secretary shall … ,” not someone else, “the secretary shall … .” And so, at the end of the day, you get to sort of weigh it. And so it’s a pleasure to work with very talented, committed people.

Sebelius: Julie, I want to throw in one more thing, because I think this is back to what people don’t know, but it’s also about our days. There’s an assumption, when administrations change, the whole agency changes, right? Washington all changes. In a department like HHS, 90,000 employees scattered in the country and around the world, there are about 900 total political appointees, and they are split among all the agencies and the secretary’s office there. So you’re really talking about this incredibly talented team of professionals who are running those agencies and have all the health expertise, with the few people across the top that may try to change directions and put — but I think there’s an assumption that sort of the whole group sweeps out and somebody else sweeps in, and that really is not the case.

Rovner: So, as I mentioned, all three of you had relevant government experience before you came to HHS. Secretary Sebelius, you were a governor, so you knew about running a large organization. I want to ask all three of you, did you really understand what you were getting into when you became secretary? And is there some way to grow up to become HHS secretary?

Azar: I mean, yeah, I — yeah, I have no excuse. My first day, right after getting sworn in — the secretary has a private elevator that goes directly up to the sixth floor where the suite is, the deputy secretary’s office to the right, secretary to the left — my first day, I’m up, headed up with my security detail, and I get off and I walk off to the right. “Mr. Secretary, no, no, no. It’s this way.” Literally, it was like — it had been 11 years, but it was like coming home to me. I was literally about to walk into my old office as deputy secretary, and they show me to the secretary’s office. And I think for the first three months, I kept thinking Tommy Thompson or Mike Leavitt was going to walk in and say, “Get the hell out of my office.” And no, so it, and it was the same people, as Secretary Sebelius said. I knew all the top career people. I’d worked with them over the course of — in and out of government — 20 years. So it was very much a “coming home” for me. And it was many of the same issues were still the same issues. Sustainable growth rate — I mean, whatever else, it was all the same things going on again, except the ACA was new. That was a new nice one you gave me to deal with also. So, yeah, thank you.

Sebelius: You’re welcome. We had to have something new.

Rovner: What were you unprepared for when you took on this job?

Azar: Well, for me, the Trump administration.

Rovner: Yeah, that’s fair.

Azar: I, you know, had come out of the Bush administration. You’re at Eli Lilly. I mean, you know, you’re used to certain processes and ways people interact. And, you know, it’s just — it was different.

Sebelius: I had a pretty different experience. The rhythm of being a governor and being a Cabinet secretary is pretty similar. Cabinet agencies, working with the legislative process, the budget. So I kind of had that sense. I had no [Capitol] Hill experience. I had not worked on the Hill or served on the Hill, so that was a whole new entity. You’re not by protocol even allowed in the department until you’re confirmed. So I had never even seen the inside of the office. I mean, Alex talked about being confused about which way to turn. I mean, I had no idea [about] anything on the sixth floor. I hadn’t ever been there. My way of entering the department — I was President [Barack] Obama’s second choice. [Former South Dakota Democratic Senator] Tom Daschle had been nominated to be HHS secretary. And that was fine with me. And I said, “I’m a governor. I’ve got two more years in my term. I’ll join you sometime.” And then when Sen. Daschle withdrew, the president came back to me and said, “OK, how about, would you take this job if you’re able to get it?” And I said, “Yes, that’s an agency that’s interesting and challenging.” So I still was a governor, so I was serving as governor, flying in and out of D.C. to get briefings so I could go through hearings on this department that I didn’t know a lot about and had never really worked with, and then would go back and do my day job in Kansas. And the day that the Senate confirmation hearing began, a call came to our office from the White House. And this staffer said, “This governor? “Yes.” “President Obama has a plane in the air. It’s going to land at Forbes Air Force Base at noon. We want you on the plane.” And I said, you know, “That’s really interesting, but I don’t have a job yet. And I actually have a job here in Kansas. And here’s my plan. You know, my plan is I’m going to wait until I get confirmed and then I’ll resign and then I’ll get on the plane and then I’ll come to D.C.” And they said, “The president has a plane in the air, and it will land. He wants you on the plane.” First boss I’d had in 20 years. And I thought, “Oh, oh, OK. That’s a new thing.” So I literally left. Secretary Azar has heard this story earlier, but I left an index card on my desk in Kansas that said, “In the event I am confirmed, I hereby resign as governor.” And it was notarized and left there because I thought, I’m not giving up this job, not knowing if I will have another job. But halfway across the country I was confirmed and they came back and said — so I land and I said, “Where am I going?” I, literally, where — I mean, I’m all by myself, you know, it’s like, where am I going? “You’re going to the White House. The president’s going to swear you in.” “Great.” Except he couldn’t swear me in. He didn’t have the statutory authority, it turns out, so he could hold the Bible and the Cabinet secretary could swear me in. And then I was taken to the Situation Room, with somebody leading the way because I’d never been to the Situation Room. And the head of the World Health Organization was on the phone, the health minister from Canada, the health minister from Mexico, luckily my friend Janet Napolitano, who was Department of Homeland Security secretary — because we were in the middle of the H1N1 outbreak, swine flu, nobody knew what was going on. It was, you know, an initial pandemic. And everybody met and talked for a couple of hours. And then they all got up and left the room and I thought, woo-hoo, I’m the Cabinet secretary, you know, and they left? And somebody said to me later, well, “Does the White House find you a place to live?” I said, “Absolutely not. Nobody even asked if I had a place to stay.” I mean, it was 11 o’clock at night. They were all like, “Good night,” “goodbye,” “see ya.” So I luckily had friends in D.C. who I called and said, “Are you up? Can I come over? I’d like somebody to say, ‘Yay,’ you know, ‘we’re here.’” So that’s how I began.

Rovner: So you are kind of between these two. You have at least a little more idea of what it entailed. But what were you unprepared for in taking on this job?

Becerra: Probably the magnitude. Having served in Congress, I knew most of the agencies within HHS. I had worked very closely with most of the bigger agencies at HHS. As AG — Alex, I apologize — I sued HHS quite a —

Azar: He sued me a lot.

Becerra: Quite a few times.

Azar: Becerra v. Azar, all over the place.

Becerra: But the magnitude. I thought running the largest department of justice in the land other than the U.S. Department of Justice was a pretty big deal. But then you land and you have this agency that just stretches everywhere. And I agree with everything that Kathleen said earlier about the role that we play internationally. We are some of the best ambassadors for this country in the world because everyone wants you to help them save lives. And so it really helps. So the magnitude — it just struck me. When President Biden came in, we lost the equivalent of about — what, 13 9/11 twin tower deaths one day. Every day we were losing 11 twin tower deaths. And it hits you: You’ve got to come up with the answer yesterday. And so the White House is not a patient place, and they want answers quickly. And so you’re just, you’re on task. And it really is — it’s on you. You really — it smothers you, because you can’t let it go. And whether it was covid at the beginning or monkeypox last year, all of a sudden we see monkeypox, mpox, starting to pop up across the country. And it was, could this become the next covid? And so right away you’ve got to smother it. And the intensity is immediate. Probably the thing that I wasn’t prepared for as well, along with the magnitude, was, as I said, the breadth. Came in doing all these Zooms virtually to try to deal with the pandemic. But probably the thing that I had to really zero in on even more, that the president was expecting us to zero in on more, was migrant kids at the border and how you deal with not having a child sleep on a cement floor with an aluminum blanket and just trying to deal with that. It won’t overwhelm you necessarily, but — and again, thank God you’ve got just people who are so committed to this, because at any hour of the day and night, you’re working on these things — but the immensity of the task, because it’s real. And other departments also have very important responsibilities — clearly, Department of Defense, Department of State. But really it truly is life-and-death at HHS. So the gravity, it hits you, and it’s nonstop.

Rovner: All three of you were secretary at a time when health was actually at the top of the national agenda — which is not true. I’ve been covering HHS since 1986, and there have been plenty of secretaries who sort of were in the back of the administration, if you will, but you all really were front and center in all of these things. I want to go to sort of down the line. What was the hardest decision you had to make as secretary?

Becerra: Um …

Rovner: You’re not finished yet. I should say so far.

Becerra: I mean, there have been a lot of tough decisions, but, you know, when your team essentially prepares them up and you have all this discussion, but by the time it gets to me, it really has been baked really, really well. And now it’s sort of, White House is looking at this, we are seeing some of this, we’ve got to make a call. And again, Dr. Califf could speak to this as well. At the end of the day, the decisions aren’t so much difficult. It’s that they’re just very consequential. Do you prepare for a large surge in omicron and therefore spend a lot of money right now getting ready? Or do you sort of wait and see a little bit longer, preserve some of your money so you can use some of that money to do the longer-term work that needs to be done to prepare for the next generation of the viruses that are coming? Because once you spend the dollar, you don’t have it anymore. So you got to make that call. Those are the things that you’re constantly dealing with. But again, it just really helps to have a great team.

Sebelius: So I would say I was totally fortunate that the pandemic we dealt with was relatively short-lived and luckily far, far milder than what consumed both the secretaries to my left and right, and that was fortunate. A lot of our big decision areas were under the rubric of the Affordable Care Act and both trying to get it passed and threading that needle but then implementation. And I — you know, thinking about that question, Julie, I would say one of the toughest decisions — just because it provided a real clash between me and some of the people in the White House; luckily, at the end of the day, not the president, but — was really about the contraception coverage. Reproductive health had been something I’d worked on as a legislator, as governor. I felt very strongly about it. We’d fought a lot of battles in Kansas around it, and part of the Affordable Care Act was a preventive services benefit around contraceptive care. And that was going to be life-changing for a lot of women. And how broad it should be, how many battles we were willing to take on, how that could be implemented became a clash. And I think there were people in the administration who were hopeful that you could avoid clashes. So just make a compromise, you know, eliminate this group or that group, who may get unhappy about it. And at the end of the day, I was helped not just by people in the department, but mobilized some of my women Cabinet friends and senior White House women friends. And we sort of had a little bit of a facedown. And as I say, the president ended up saying, “OK, we’ll go big. We’ll go as big as we possibly can.” But I look back on that as a — I mean, it was a consequential decision, and it was implementation — not passing the rag in the first place, but implementing it. And it had a big impact. A big impact. It’s not one I regret, but it got a little a little tense inside, but what would be friendly meetings.

Azar: I’d use the divide Secretary Becerra talked about, which is that consequential versus hard decisions, that a lot — I think one could have a Hamlet-like character. I don’t. And so making the call when it comes to you wasn’t a terribly difficult thing, even. These are life-and-death decisions, but still yourself, you know your thought processes, you think it through, it’s been baked very well, you’ve heard all sides. You just have to make that call. So I’d maybe pivot to probably it’s more of a process thing. The hardest aspect for me was just deciding when do you fight and when do you not fight with, say, the White House? What hills do you die on? And where do you say, “Yeah, not what I would do, but I just have to live to fight another day.” Those were probably the toughest ones to really wrestle with.

Rovner: Was there one where you really were ready to die on the hill?

Azar: There were a lot. There were a lot. I mean, I’ll give you one example. I mean, I left a lot of blood on the field of battle just to try to outlaw pharmaceutical rebates, to try to push those through to the point of sale. I probably stayed to the end just to get that dag — because I, the opponents had left the administration and I finally got that daggone rule across the finish line right at the end. And that was something that I felt incredibly strongly that you could never actually change. I’ve lived inside that world. You could never change the dynamic of pharmaceutical drug pricing without passing through rebates to the point of sale. And I had so many opponents to get that done. It was a three-year constant daily battle that felt vindicated then to get it done. But that was a fight.

Rovner: And of course, I can’t help but notice that all of the things that you all are talking about are things that are still being debated today. None of them are completely resolved. Let’s turn this around a little bit. I wanted to ask you what you’re most proud of actually getting accomplished. Was it the rebate rule? That was a big deal.

Azar: For me, it has to be Operation Warp Speed. …[applause] … Yeah. Thank you. That was just — I mean, and I don’t want to take the credit. I mean, it was public-private. Mark Esper, this could not have happened without the partnership of the Defense Department, and it could not have happened without Mark Esper as secretary, because — I guarantee you, I’ve dealt with a lot of SecDefs in my career — and when the secretary of defense says to you, “Alex, you have the complete power and support of the Department of Defense. You just tell me what you need.” I haven’t heard those words before. And he was a partner and his whole team a partner throughout. And when you have the muscle of the U.S. military behind you to get something done, it is miraculous what happens. I mean, we were making hundreds of millions of doses of commercial-scale vaccine in June of 2020, when we were still in phase 2 clinical trials. We were just making it at risk. So we’re pumping this stuff out. And in one of the factories, a pump goes down. The pump is on the other side of the country on a train. The U.S. military shoots out a fighter jet, it gets out there, stops the train, pulls the train over, puts it on a helicopter, gets it on the jet, zips it off to the factory. We have colonels at every single manufacturing facility, and they get this installed. We’re up and running within 24 hours. It would have taken six to nine months under normal process. But the U.S. military got that done. So that for me was like just — the other two quick, one was banning flavored e-cigarettes. We got 25% reduction in youth use of tobacco in 12 months as a result of that. And then one of the great public health victories that this country had and the world had got ignored because it got concluded in June of 2020: We had the 11th Ebola outbreak. It was in the war zone in the eastern Democratic Republic of the Congo. This was the pandemic I was really, really worried about. One-hundred seventy-four warring groups in the war zone in the eastern Congo. Got [WHO Director-General] Tedros [Adhanom Ghebreyesus] and [then-Director of the National Institute of Allergy and Infectious Diseases Anthony] Fauci and [then-CDC Director Robert] Redfield, and we went over and we went on the ground and we got that. And by June of 2020, that one got out, which was a miracle of global public health. I’m with Kathleen on that one; I think global public health is a key instrument of American power projection humanity around the world. Sorry to go so long.

Rovner: It’s OK. Your turn.

Sebelius: I think proudest is the ability to participate in the Affordable Care Act and push that over the finish line. And for me, it was a really personal journey. My father was in Congress and was one of the votes for Medicare and Medicaid to be passed, so that chunk of the puzzle. I was the insurance commissioner in Kansas when the Republican governor asked me to do the implementation of the Children’s Health Insurance Program. So I helped with that piece. I was on President [Bill] Clinton’s patient protection commission and ended up with a lot of that package in the Affordable Care Act. And then finally to work for and support and watch a president who basically said when he announced for president, “This is my priority in my first term: I want to pass a major health care bill.” And a lot of people had made that pledge. But 15 months later, there was a bill on his desk and he signed it, and we got to implement it. So that was thrilling. Yeah. And, I should tell you, then-Congressman Becerra was one of the wingmen in the House who I worked with carefully, who — there was no better vote counter than Nancy Pelosi, but by her side was this guy, part of her delegation, named Xavier Becerra, who was whipping the votes into place. So he played a key role in making sure that crossed the finish line.

Becerra: So I’m still here, so you’re going to have to —

Rovner: You can change your answer later.

Becerra: I need a bit of grace here, because I’m going to start with Warp Speed, because I bet no one here knows there’s no longer a Operation Warp Speed. It’s now called H-CORE. And the reason I’m very proud of that is because you don’t know that it’s now H-CORE. And what makes it such a good thing is that the Department of Defense no longer has any role in the protection of the American people from covid. It’s all done in-house at HHS. Everything used to be done essentially under the auspices of the Department of Defense, because they are just the folks that can get things done in 24 hours. We do that now, and it’s the operations that were begun a while back. Kathleen had them, Alex had them. Our ASPR, that’s our Preparedness and Response team, they’re doing phenomenal work, but you don’t know it, and you don’t know that H-CORE took to flight in the first year of the Biden administration. By December of 2021, Department of Defense had transferred over all those responsibilities to us, and we’ve been doing it since. But if you ask me what am I most proud of, it’s, I mean, there are more Americans today than ever in the history of this country who have the ability to pay for their own health care because they have health insurance, more than 300 million. Part of that is Obamacare; a record number, 16 and a half million Americans, get their insurance through the marketplaces, and we haven’t stopped yet. There are close to 700 million shots of covid vaccine that have gone into the arms of Americans. That’s never been done in the history of this country. Some of you are probably familiar with three digits, 988, at a time when Americans are … [applause] … 9 in 10 Americans would tell you that America is experiencing a mental health crisis, especially with our youth. And Congress got wise and said, instead of having in different parts of the country, based on region, you could call a phone number for a suicide lifeline, if you didn’t know the 10-digit number or what part of the country you were in, you were out of luck — today, all you have to do is dial 988. But as I said before, federal government doesn’t run mental health. It’s all done by the states. But President Biden is very committed to mental health. His budgets have surpassed any type of investments that have been called for by any president in history for mental health. And he was very committed to 988 to make sure it launched right. And so we have, by exponential numbers, put money into 988 to make sure every state was ready to have it launch. And so by July of 2022, we launched 988, and it is working so well that people are actually calling — actually, not just calling. We now have a text feature and a chat feature because surprise, surprise, young people prefer not to call; they actually prefer to text. And we have increased the number of Americans who are reaching out by over 2 million, which is great, but it’s also not great because it shows you how much Americans are hurting. So there’s so many things I can tell you that I feel very good about that we’re doing. We’re not done. We’re moving beyond on tobacco where Alex left. We’re now moving to ban menthol in cigarettes. Menthol cigarettes are the most popular brand of cigarettes in America. They hook you because of the menthol, and we’re moving to extract menthol. We’re moving to ban flavored cigars and cigarillos. And we may be on course to try to see if we can move to extract as much nicotine out of tobacco as possible before it becomes a product on the market for folks to smoke. So we’re doing a whole lot of things there. And obviously on vaping, e-cigarettes as well — and Dr. Califf could mention that. But I’ll say the thing I’m probably most proud of is that, out of all the government agencies in America, federal government agencies, HHS ranks No. 2 as the best place to work. And I will tell you we’re No. 2, because if we had the capacity to tell our workforce, we will fly you to the moon and back the way NASA does, we’d be No. 1. So that’s what I think I’m most proud of, is that people, as hard as we work them, still say, “Come work at HHS.”

Rovner: So all of you have mentioned these things that were really hard to do because of politics. And you’ve all talked about how some of these decisions, when they get to you, have been baked by your staff and, you know, they vetted it with every side. But I think the public feels like politics determine everything. And I think you all would like to think that policy is what helps determine most things. So, what’s the balance? How much does politics determine what gets done, and how much is it just the idea that this would be the right policy for the American public?

Azar: Mike Leavitt, who was the secretary when I was deputy secretary, he had a phrase, and I’ll probably mangle it, but it was essentially, “Facts for science, and politics for policy.” And it’s important to remember this distinction. So, facts are facts. You gather data. We are especially a data-generating agency. But on top of that are policy overlays. And there are choices that are made about how do you use those facts? What do those facts mean? What are the implications? The United States Constitution vests under Article 2 in the president of the United States to make those choices and, as his delegee, the secretary and the other appointed leaders of the department. So there’s often this notion of politicizing science, but it’s, are there facts? Facts are facts. You generate facts. But what are the implications for policymaking? And I don’t think there’s anything illegitimate — I think is completely appropriate, whether a Democratic or Republican president — that you look and you consider all kinds of factors. Because for instance, for me, I’m going to look at things very much from a public health lens as I assess things. The secretary of the treasury, the secretary of commerce, may bring a completely and important different perspective to the table that I don’t bring. And it’s completely legitimate that that gets factored on top of whatever I or other agencies bring in as fact. So I think it takes some nuance and that we often, frankly, in public discourse don’t catch nuance. Interesting. We don’t do nuance well.

Rovner: We don’t do nuance.

Sebelius: Well, I would agree with the description of the facts versus the policy. And policy does often have political flavors. I was fortunate to work for a president who said, meant, and said it over and over and over again that he would follow the science. And he did. And I had interesting political debates with people around him, on his team, about what should be done, “rewrite the guidance on this,” “do that,” “this is going to upset this group of people.” And he was very resilient and very consistent, saying, “What does the science say? What do the scientists say? That’s where we’re going,” on those areas which were really defined as giving advice to the American public on health issues, doing a variety of things. I mean, he was totally focused on listening to the science. The politics came in, as I think Secretary Azar said well, in some decisions that were brought to him, which really involved often battles between Cabinet agencies, and both were very legitimate. Again, we had pretty ferocious battles on food labeling and calorie counts and how much sodium would, should manufacturers be allowed to put in all of our manufactured goods. I’m sure many of you are aware, but, you know, American sodium levels are just skyrocketing. And it doesn’t matter what kind of salt you use at your table; it’s already baked into every loaf of bread, every pat of butter, every can of soup. And a lot of European countries have done a great job just lowering that. So the goods that are manufactured that you pick up in an EU country — Kellogg’s Corn Flakes has a third of the sodium that the Kellogg’s Corn Flakes that you get in Aspen does, just because that was a choice that those governments made. That’s a way to keep people healthy. But we would come at that through a public health perspective and argue strenuously for various kinds of limits. The Department of Agriculture, promoting farm products, supporting goods it exports, you know, not wanting to rile people up, would come in very strongly opposing a lot of those public health measures. And the president would make that call. Now, is that politics? Is it policy? Is it, you know, listening to a different lens? But he made the call and some of those battles we would win and some we would lose. But again, it’s a very legitimate role for the president to make. He’s getting input from leaders who see things through a different lens, and then he’s the ultimate decider and he would make the decision.

Becerra: So um, I’ve done politics and policy much longer than I’ve done the secretary role. And I will tell you that there is a big difference. We do do some policy, but for the most part we execute. The policy has been given to us by Congress, and to some degree the White House will help shape that policy. We have some role in policymaking because we put out guidances, and the guidance may look like it’s political or policy-driven, or we decide how much sodium might be allowed in a particular product and so forth. But for the most part, we’re executing on a policy that’s been dictated to the agencies by Congress. And I love that, because when I became AG in California, it really hit you how important it is to be able to marshal facts. And in HHS, it’s not just facts; it’s scientific facts. It is such a treat, as an attorney, to get to rely on scientific facts to push things like masking policy in the face of some hostility that went throughout the country to the point that our CDC director had to have security detail because she was getting death threats for having policies that would urge society to have masking policies for adults, for children. We do rely principally on science and the facts at HHS. Maybe folks don’t believe it, but I can put those on the table for you to take a look at. And perhaps the best example I can give you, and I don’t know if I’ll have time to connect the dots for you, because it’s a little esoteric: Title 42, which many of you got to hear about all the time in the news. Title 42 was a policy that was put in place under the Trump administration when we were in the height of the covid pandemic. We didn’t know what was causing covid, so we were trying to make sure that we protected ourselves and our borders. And so therefore, for public health reasons, we sort of closed our borders to the degree that we could, except for those who proved that they had gone through steps and so forth to be able to come in. Title 42 was used under the Trump administration, under the Biden administration to stop people from coming through our southern border. And there reached a point where, as things got better, our team said Title 42, which is health-based — it’s to stop the spread of contagion — was no longer the appropriate tool to use at the border, because we were letting people in the northern border, by plane, and all the rest. You just had to go through protocols. And so they were saying for health care reasons you go through protocols. But Title 42 is probably not the blanket way to deal with this issue, because it’s no longer simply a health care issue. We pushed really hard on that within the administration to the point where, finally, the administration said, “We’re pulling down Title 42.” Then the politics and the policy came in, from Congress saying, “Oh, how dare you take down Title 42? How dare you do that and let the flood of people come into this country?” Well, look, if you want to deal with people coming into the country, whatever way, then deal with our country’s borders through our immigration laws, not through our health care laws. Don’t try to make health care experts be the reason why you’re stopping someone from coming into this country. Stop hiding behind their skirt. And that’s where we went. And the administration took that policy as well. They took the policy. We then got sued and a court said, “No, you will not take down Title 42.” Ultimately, we think we were going to prevail in court, but ultimately, because we pulled down the public health emergency, things got better under covid, we no longer needed Title 42. But just again, to be clear, the women and men at HHS, we execute; we use the facts and the science. We don’t do politics.

Rovner: So we’ve been very serious.

Becerra: Not everybody believed me on that one.

Rovner: I know, I know. We’ve been very serious here for 50-some minutes. I want to go down the line. What’s the most fun thing you got to do as secretary or the coolest thing that you got to do as secretary?

Azar: Probably for me, it was the trip to the Congo, you know, being in the DRC, going to Uganda, going to Rwanda, flying on MONUSCO [United Nations Organization Stabilization Mission in the Democratic Republic of the Congo] U.N. peacekeeping forces; there was a Russian gunboat taking Tedros and Fauci and Redfield and me there into this war zone. I mean, it’s a once-in-a-lifetime — it’s sort of crazy — but once-in-a-lifetime thing that had impact.

Rovner: I don’t know that most people would call that fun.

Azar: I mean, it’ll be one of those great memories for life. Yeah. Yeah.

Sebelius: There were certainly some great trips and memorable experiences around health results in various parts of the world. Some martinis on the presidential balcony and looking at the Washington Monument — that’s pretty cool at night. But my, I think, personally kind of fun thing. I raised my children on “Sesame Street,” and they loved “Sesame Street” and the characters, and that was sort of part of the family routine. And so I got to go to “Sesame Street” and make a public service commercial with Elmo. I got to see Oscar’s garbage can. I met Snuffleupagus. But the Elmo commercial was to teach kids how to sneeze because, again, we were trying to spread good health habits. And so the script said — I mean, Elmo is right here and I’m here — and the script said, “OK, Elmo, we need to practice how to sneeze. So put your arm up and bend your elbow and sneeze into your arm.” And the puppet answered, “Elmo has no elbow.” That wasn’t part of the script. It was like, really? “And if Elmo does that, it will go like this: Achoo!” OK, so we flipped the script and Elmo taught me to sneeze. But that was a very memorable day to finally be on “Sesame Street.” It was very cool.

Rovner: OK, beat that.

Becerra: My team has not yet scheduled me to go on “Sesame Street,” so it’s going to be tough.

Sebelius: But just remember, Elmo has no elbows, if you get to go.

Becerra: I think probably what I will think of most is that I had had a chance to be in the White House and meet with the president in the Oval Office and the rest as a of member of Congress and so forth. When I went in, and it was because things were kind of dire with the kids at the border, and I knew I was going to get a whiplash after the meeting — it wasn’t fun at the time, but walking out, you know, it’s the kind of thing you think of, you know, “West Wing” kind of thing. You actually got the — president sat at the table, I was the guy that sat across from him. Everybody else was to the sides. You know, for a kid who was the first in his family to go to college, Dad didn’t get past the sixth grade, Mom didn’t come here till she was 18, when she came from Guadalajara, Jalisco, Mexico. It was pretty cool.

Rovner: So I could go on all night, but I think we’re not supposed to. So I want to ask you all one last question, which is, regardless of party affiliation, what is one piece of advice you would give to a successor as HHS secretary? Why don’t you start?

Becerra: Gosh, don’t start with me because I’m still there, so —

Rovner: All right.

Azar: I’m going to plagiarize and I’m going to give you the advice I wish Donna Shalala had given me before I took the job. But I would give it to any successor, which: She told me, “Do not take the job unless you have authority over personnel. Refuse to take the job unless you have control over who’s working, because people is policy and you have to be able to control the ethics, the tone, the culture of the organization. And people are that, and you need to have that authority.” And ever really since the Reagan administration, the Office of Presidential Personnel has just been this vortex of power that controls all political appointees at Cabinet departments. And I think if the president really wants you, you need to strike a deal that says, at a minimum, I’ve got veto or firing rights.

Sebelius: I think my advice would be the advice you give to a lot of employees who work in the private sector or public sector is, Make sure you’re aligned with the mission of the CEO, so in this case the president. I mean, don’t take the job because it’s cool and you’ll be a Cabinet member, because then it will be miserable. And with HHS, recognize the incredible assets across this agency. It is the most dazzling workforce I’ve ever had an opportunity to be with — the brightest people of all shapes, sizes, backgrounds, who taught me so much every day — and just cherish and relish your opportunity to be there, even for a short period of time. It’s miraculous.

Becerra: So I’d agree with Alex: Assemble your team. And it really is, because Kathleen mentioned it, it’s a very small group that actually you get to bring in, or even the administration gets to bring in, because most of the folks are civil service, so it’s only a fraction of the people that are going to be new. But your inner circle, the team that’s going to sort of be there and guide you and tell you what’s truth, they’ve got to be your team, because someone’s got to have your back. But I’d also say, know your reach, because as Kathleen said, this is not the Azar administration or the Sebelius administration, the Becerra administration. It’s the administration of the guy who got elected. And at the end of the day, the president gets to make the call. So as much as you may want to do something, you’ve got to know your reach.

Rovner: Well, I want to thank you all. I hope the audience had half as much fun as I did doing this. Let’s do it again next year. Thank you, all. OK, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Special thanks, as always, and particularly this week, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner. We’ll be back in your feed from Washington next week. Until then, be healthy.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ “What the Health?” on Spotify, Apple Podcasts, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

2023 will likely be remembered as the summer Arizona sizzled, Vermont got swamped, and nearly the entire Eastern Seaboard, along with huge swaths of the Midwest, choked on wildfire smoke from Canada. Still, none of that has been enough to prompt policymakers in Washington to act on climate issues.

Meanwhile, at a public court hearing, a group of women in Texas took the stand to share wrenching stories about their inability to get care for pregnancy complications, even though they should have been exempt from restrictions under the state’s strict abortion ban.

This week’s panelists are Julie Rovner of KFF Health News, Rachel Cohrs of Stat, Shefali Luthra of The 19th, and Alice Miranda Ollstein of Politico.

Panelists

Rachel Cohrs
Stat News

@rachelcohrs

Read Rachel's stories

Shefali Luthra
The 19th

@shefalil

Read Shefali's stories

Alice Miranda Ollstein
Politico

@AliceOllstein

Read Alice's stories

Among the takeaways from this week’s episode:

• Tensions over abortion access between the medical and legal communities are coming to the fore in the courts, as doctors beg for clarification about bans on the procedure — and conservative state officials argue that the law is clear enough. The risk of being hauled into court and forced to defend even medically justified care could be enough to discourage a doctor from providing abortion care.
• Conservative states are targeting a Biden administration effort to update federal privacy protections, which would make it more difficult for law enforcement to obtain information about individuals who travel outside a state where abortion is restricted for the procedure. Patient privacy is also under scrutiny in Nebraska, where a case involving a terminated pregnancy is further illuminating how willing tech companies like Meta are to share user data with authorities.
• And religious freedom laws are being cited in arguments challenging abortion bans, with plaintiffs alleging the restrictions infringe on their religious rights. The argument appears to have legs, as early challenges are being permitted to move forward in the courts.
• On Capitol Hill, key Senate Democrats are holding up the confirmation process of President Joe Biden’s nominee as director of the National Institutes of Health to press for stronger drug pricing reforms and an end to the revolving-door practice of government officials going to work for private industry.
• And shortages of key cancer drugs are intensifying concerns about drug supplies and drawing attention in Congress. But Republicans are skeptical about increasing the FDA’s authority — and supply-chain issues just aren’t that politically compelling.

Also this week, Rovner interviews Meena Seshamani, director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services.

Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:

Julie Rovner: Los Angeles Times’ “Opinion: Crushing Medical Debt Is Turning Americans Against Their Doctors,” by KFF Health News’ Noam N. Levey.

Rachel Cohrs: The New York Times’ “They Lost Their Legs. Doctors and Health Care Giants Profited,” by Katie Thomas, Jessica Silver-Greenberg, and Robert Gebeloff.

Alice Miranda Ollstein: The Atlantic’s “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch.

Shefali Luthra: KFF Health News’ “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care,” by Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West.

Also mentioned in this week’s episode:

• Stat’s “From Rapid Cooling Body Bags to ‘Prescriptions’ for AC, Doctors Prepare for a Future of Extreme Heat,” by Karen Pennar.
• Politico’s “The Sleeper Legal Strategy That Could Topple Abortion Bans,” by Alice Miranda Ollstein.

click to open the transcript

Transcript: Let’s Talk About the Weather

KFF Health News’ ‘What the Health?’Episode Title: Let’s Talk About the WeatherEpisode Number: 306Published: July 20, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for KFF Health News. And I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, July 20, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So here we go. We are joined today via video conference by Alice Miranda Ollstein, of Politico.

Alice Miranda Ollstein: Hello.

Rovner: Rachel Cohrs, of Stat News.

Rachel Cohrs: Hi, everybody.

Rovner: And Shefali Luthra of The 19th.

Shefali Luthra: Hello.

Rovner: Later in this episode we’ll have my interview with Meena Seshamani, director of the Center for Medicare at the Center for Medicare & Medicaid Services at the Department of Health and Human Services. She has an update on drug price negotiations, Medicare Advantage payments, and more. But first, this week’s news. So let’s talk about the weather. Seriously, this summer of intense heat domes in the South and Southwest, flash floods in the East, and toxic air from Canadian wildfires almost everywhere below the border has advertised the dangers of climate change in a way scientists and journalists and policymakers could only dream about. The big question, though, is whether it will make any difference to the people who can actually do something about it. I hasten to point out here that in D.C., it’s normal — hot and humid for July, but nothing particularly out of the ordinary, especially compared to a lot of the rest of the country. Is anybody seeing anybody on the Hill who seems at the least alarmed by what’s going on?

Ollstein: Not other than those who normally speak out about these issues. You’re not seeing minds changed by this, even as the reports coming out, especially of the Southwest, are just devastating — I mean, especially for unhoused people, just dying. I was really interested in the story from Stat about doctors moving to start prescribing things to combat heat, like prescribing air conditioners, prescribing cooling packs and other things, really looking at heat as a medical issue and not just a feature of our lives that we have to deal with.

Rovner: Well, emergency rooms are full of patients. You can now burn yourself walking on the sidewalk in Arizona. You know, last summer was not a great summer for a lot of people, particularly in California and in western Canada. But this year, it’s like everywhere across the country, everybody’s having something that’s sort of, oh, a hundred-year something or a thousand-year something. And yet we just sort of continue on blithely.

Ollstein: And just quickly, what really hits me is how much of a vicious cycle it can create, because the more people use air conditioners, those give off heat and make the bigger situation worse. So making it better for yourself makes it worse for others. Same with driving. You know, the worse the weather is, the more people have to drive rather than bike or walk or take public transit. And so it gets into this vicious cycle that can make it worse for everyone and create these so-called heat islands in these cities.

Rovner: All right. Well, let us move on to a more familiar topic: abortion and reproductive health. In case you’re wondering why it’s hard to keep track of where abortion is legal, where it’s banned, and where it’s restricted, let’s talk about Iowa. When we last checked in, last week, state lawmakers had just passed a near-total ban after the state Supreme Court deadlocked over a previous ban and the Republican governor, Kim Reynolds, was poised to sign it. Then what happened?

Luthra: The governor signed the ban right as the hearing for the ban concluded in which Planned Parenthood and another abortion clinic in the state sued, arguing, right, that this is the exact same as the law that was just struck down and therefore should be struck down again. And this judge said that he wouldn’t rush to his ruling. He wanted to, you know, give it the time that it deserved so he wouldn’t be saying anything on Friday, which meant as soon as the law was signed, it took effect. It was in effect for maybe a little over 72 hours, essentially through the weekend. And then on Monday, the judge came and issued a ruling blocking the law. And even that is temporary, right? It only lasts as long as this case is proceeding. And one of the reasons Republicans came back and passed this ban is they are hopeful that something has changed and that this time around the state Supreme Court will let the six-week ban in Iowa stand, which really just would have quite significant implications for the Midwest, where it’s been kind of slower to restrict abortion than the South has been because of the role the courts have played in Ohio, in Iowa, blocking abortion bans, and we could very soon see restrictions in Iowa, in Indiana, potentially in Ohio, depending on how the election later this year goes. And it will look like a very different picture than it did even six months ago.

Rovner: And for the moment, abortion is legal in Iowa, right?

Luthra: Correct.

Rovner: Up to 20 weeks?

Luthra: Up to 20, 22, depending on how you count.

Rovner: But as you say, that could change any day. And it has changed from day to day as we’ve gone on. Well, if that’s not confusing enough, there are a couple of lawsuits that went to court in Texas and Missouri, and neither of them is actually challenging an abortion ban. In Texas, women who were pregnant and unable to get timely care for complications are suing to clarify the state’s abortion ban so patients don’t have to literally wait until they are dying to be treated. And in Missouri, there’s a fight between two state officials over how to describe what a proposed state ballot measure would do, honestly. So what’s the status of those two suits? Let’s start with Texas. That was quite a hearing yesterday.

Luthra: It is really devastating to watch. And the hearing continues today, Thursday. And we are hearing from these women who wanted to have their pregnancies, developed complications where they knew that the fetus would not be viable, could not get care in the state. One of them who came to the State of the Union earlier this year, she had to wait until she was septic before she could get care. Another woman traveled out of state. Another one had to give birth to a baby that died four hours after being born, and she knew that this baby wouldn’t live. And it’s really striking to watch just how obviously difficult it is for these women to relive this thing that happened to them, clearly one of the worst things in their lives, maybe the worst thing. And the state’s arguments are very interesting, too, because they appear to be trying to suggest that it is actually not that the law is unclear, but that doctors are just not doing their jobs and they should do, you know, the hard work of medicine by understanding what exceptions mean and interpreting laws that are always supposed to be a little ambiguous.

Ollstein: So when states were debating abortion bans and really Republicans were tying themselves in knots over this question of exemptions — How should the exemptions be worded? Should there be any exemptions at all? Who should they apply to? — a lot of folks on the left were yelling at the time that that’s the wrong conversation, that exemptions are unworkable; even if you say on paper that people can get an abortion in a medical emergency, it won’t work in practice. And this is really fodder for that argument. This is that argument playing out in real life, where there is a medical exemption on the books, and yet all of these women were not able to get the care they needed, and some have suffered permanent or somewhat permanent repercussions to their health and fertility going forward. As more states debate their own laws, and some states with bans have even tried to go back and clarify the exemptions and change them, I wonder how much this will impact those debates.

Rovner: Yeah, I mean, if you just say that doctors are being, you know, cowards basically by not providing this care, think of it from the doctor’s point of view, and now we see why hospital lawyers are getting involved. Even if there’s a legitimate medical reason, they could get dragged into court and have to pay tens or hundreds of thousands of dollars in legal fees just to prove that their medical judgment was correct. You can kind of see why doctors are a little bit reluctant to do that.

Ollstein: And just to stress, these laws were not written by doctors. These laws were written by politicians, and they include language that medical groups have pointed out doesn’t translate to the actual practice of medicine. Some of these bans’ exceptions’ language use terms like irreversible, and they’re like, “That’s not something we say in medicine. That doesn’t fit with our training. We don’t think in terms of that.” Also, terms like life-threatening: It’s like, OK, well, is it imminently life-threatening? And even then, what does that mean? How close does someone need to be to losing their life in order to act?

Rovner: And pregnancy itself is life-threatening.

Ollstein: Right. Or something could be life-threatening in a longer-term way, you know, down the road. Other conditions like diabetes or cancer could be life-threatening even if it won’t kill you today or tomorrow. So this is a real battle where medicine meets law.

Rovner: Well, in Missouri, it’s obviously not nearly as dramatic, but it’s also — you can see how this is playing out in a lot of these states. This is basically a fight between the state attorney general and the state auditor over how much an abortion ban might end up costing the state. They’re really sort of fighting this as hard as they can. It’s basically to make it either more or less attractive to voters, right?

Ollstein: It’s similar to some of the gambits we saw in Michigan to keep the measure off the ballot or put it on the ballot in a way that some would say would be misleading to voters. So I think you’re seeing this more and more in these states after so many states, including pretty conservative states, voted in favor of abortion rights last year. You know, the right is afraid of that continuing to happen, and so they’re looking at all of these technical ways — through the courts, through the legislatures, whatever means they can — to influence the process. And Democrats cry that this is antidemocratic, not giving people a say. Republicans claim that they’re preventing big-money outside groups from influencing the process. And I think this is going to be a huge battle. Missouri and Ohio are up next in terms of voting. And after that, you have Florida and Nevada and a bunch of other states in the queue. And so this is going to continue to be something we’re discussing for a while.

Luthra: And to flag the case in Ohio, what’s happening there, right, is the state is having voters vote onto whether to make it harder to pass constitutional amendments. There’s an election in August that would raise the threshold to two-thirds. And what we know from all of the evidence why they don’t typically have August referenda in Ohio is because the turnout is very, very low, and they are expecting that to be very low. And they’ve made it explicit that the reason they want to make it harder to pass constitutional amendments is, in fact, the concern around Ohio’s proposed abortion protection.

Rovner: Of course, that’s what they said about Kansas last year, that people wouldn’t vote because it was in the summer, so — but this is a little bit more obtuse. This is whether or not you’re going to change the standard for passing constitutional change that would enshrine abortion. So, yeah, clearly —

Luthra: It’s hard to get people excited about votes on voting.

Rovner: Yeah, exactly. An underlying theme for most of this year has been efforts by states that restrict or ban abortion to try to prevent or at least keep tabs on patients who leave the state to obtain a procedure where it is legal. Attorneys general in a dozen and a half states are now protesting a Biden administration effort to protect such information under HIPAA, the medical records privacy provisions of the Health Insurance Portability and Accountability Act. Alice, you’ve written about this. What would the HIPAA update do, and why do the red states oppose it?

Ollstein: The HIPAA update, which was proposed in April, and comment closed in June, and so we’re basically waiting for a final rule — at some point, you know, it can take a while — but it would make it harder for either law enforcement or state officials to obtain medical information about someone seeking an abortion, either out of state or in state under one of these exemptions. This would sort of beef up those protections and require a subpoena or some form of court order in order to get that data. And you have sort of an interesting pattern playing out, which you’ve seen just throughout the Biden administration, where the Biden administration hems and haws and takes an action related to abortion rights and the left says it’s not good enough and the right says it’s wild overreach and unconstitutional and they’re going to sue. And so that’s what I was documenting in my story.

Rovner: Is it 18 red states saying —

Ollstein: Nineteen, yes, yeah.

Rovner: Nineteen red states saying that this is going too far.

Ollstein: They say they want to be able to obtain that data to see if people are breaking the law.

Rovner: Well, Shefali, you wrote this week about sort of a related topic, whether states can use text or social media messages as evidence of criminal activity. That sounds kind of chilling.

Luthra: Yeah, and this is, I think, a really interesting question. We saw it in this case in Nebraska, where a sentencing for one of the defendants is happening today in fact. And I want to be careful in how I talk about this because it concerns a pregnancy that was terminated in April of 2022, before Roe was even overturned. But it sort of offered this test case, this preview for: If you do have law enforcement going after people who have broken a state’s abortion laws, how might they go about doing that? What statutes do they use to prosecute? And what information do they have access to? And the answer is potentially quite a lot. Organizations like Meta and Google are quite cooperative when it comes to government requests for user data. They are quite willing to give over history of message exchanges, history of your searches, or of, you know, where you were tracked on Google Maps. And the bigger question there is how likely are we to see individual prosecutors, individual states, going after patients and their families, their friends for breaking abortion laws? Right now, there’s been some hesitation to do that because the politics are so terrible. But if they do go in that direction, people’s internet user data is, in most states, unprotected. There is no federal law protecting, you know, your Facebook messages. And it could be quite a useful piece of information for people trying to build a case, which should raise concern for anyone trying to access care.

Rovner: Yeah, this is exactly why women were taking their period-tracking apps off of their phones, to worry about the protection of quite personal information. Well, finally this week on the abortion front, we have talked so, so much about how conservative Christians complain that various abortion and even birth control laws violate their religious beliefs. Well, now representatives of several other religions, including Judaism and even some of the more liberal branches of Christianity, say that abortion bans violate their right to practice their religion. This is going on in a bunch of different states. I think the first one we talked about was Florida, I think a year ago. Are any of these lawsuits going anywhere? Do we expect this to end up before the Supreme Court at some point?

Ollstein: So most of them are in state court, not federal. I mean, it’s always possible it could go to the Supreme Court. A couple of them are in federal court and a couple of them have already reached the appeals court level. But the experts I talked to for my story on this said this is mainly going to have an impact in state courts and how they interpret state constitutions. A lot of states have stronger language around religious protections than the federal Constitution, including some laws that pretty conservative state leaders passed in the last few years, and I doubt they expected that same language would be cited to defend abortion rights. But here we are. And yeah, a Missouri court recently ruled that the lawsuit can go forward, the religious challenge to the state’s abortion ban. It’s a coalition of a bunch of different faith leaders bringing that challenge. And in Indiana, they won a preliminary ruling on that case. And there are others pending in Kentucky, Florida, a bunch of other states. And so, yeah, I think this definitely has legs.

Rovner: Yeah, we’re all learning an awful lot about court procedure in lots of different states. Let us move to Capitol Hill, where Congress is in its annual July race to the August recess. Seriously, this is actually a month in which Congress typically does get a lot done. Maybe not so much this year. One perhaps unexpected holdup in the U.S. Senate is where the confirmation of Monica Bertagnolli, President Biden’s nominee to head the National Institutes of Health, is being held up not by a Republican but by two Democrats: health committee chair Bernie Sanders, another member of the committee, Elizabeth Warren. Rachel, what is going on with this?

Cohrs: Sen. Bernie Sanders has long wanted the Biden administration to be more aggressive on drug pricing. And there is one issue in particular that Sen. Sanders has wanted the NIH specifically to use to challenge drug companies’ patents or at least put some pricing protections in there for drugs that are developed using publicly funded research. And the laws that the NIH potentially could use to challenge these companies for high-priced medications have never been used in this way. And Sen. Sanders is using his bully pulpit and the main leverage he has, which is over nominations, to get the White House’s attention. And I think the White House’s position here is that they have done more than any administration in the past 20 years to lower drug prices.

Rovner: Which is true.

Cohrs: It is true. And — but Sen. Sanders still is not satisfied with that and wants to see commitments from the White House and from NIH to do more.

Rovner: And Sen. Elizabeth Warren.

Cohrs: Sen. Elizabeth Warren, yes, who my colleague Sarah Owermohle first reported had some concerns over the revolving door at NIH and wanted a commitment that the nominee wouldn’t go to lobby or work for a large pharmaceutical company for four years after leaving the position, and I don’t know that she’s agreed to that yet. So I don’t see where this resolves. It’s tough, because we’re looking so close to an election, and I think there are big questions about what breaks this logjam. But it certainly has slowed down what looked like a very smooth and noncontroversial nomination process.

Rovner: Yeah, I mean, obviously, you know, we’ve seen many, many times over the years nominations held up for other reasons — I mean, basically using them as leverage to get some policy aim. It’s more rare that you see it on the president’s own party but obviously, you know, not completely unprecedented. Certainly in this case we have a lot of things to be worked out there. Well, Sen. Sanders also seems to be threatening the reauthorization of one of his very pet programs, the bipartisanly popular community health centers. His staff this week put out a draft bill and announced a markup before sharing it with Republicans on the committee. Now Ranking Member Bill Cassidy, who also supports the community health centers program — almost everybody in Congress supports the community health centers program — Cassidy complains there’s no budget score, that the bill includes programs from outside the committee’s jurisdiction, and other details that can be very important. Is Sanders trying to make things partisan on purpose, or is this just sloppy staff work?

Cohrs: Honestly, I can’t answer that question for you, but I don’t think that it’s going to result in a productive outcome for the community health centers. And I think we have in recent years seen significant cooperation between the chair and ranking member, but with Lamar Alexander, with Richard Burr, with Patty Murray, you know, we have seen a lot civility on this committee in the recent past, and that appears to have ended. And I think Sen. Cassidy’s response that he hadn’t seen the legislation publicly was, I think, telling. We don’t usually see that kind of public fighting from a committee chair.

Rovner: He put out a press release.

Cohrs: Right, put out a press release. Yeah. This is not what we usually see in these committees. And it is true that Sen. Sanders’ bill is so much more money than I think is usually given to community health centers in this reauthorization process. I think it’s true that the bill that he dropped touches issues that would anger almost every other stakeholder in the health care system. And I don’t think Sen. Cassidy quite envisioned that. And he introduced his own bill that would have introduced —

Rovner: Cassidy introduced his own bill.

Cohrs: Yes, Sen. Cassidy introduced his own bill last week that would have continued on with what the House Energy and Commerce Committee had passed unanimously earlier this summer to give community health centers a more modest boost in funding for two years.

Rovner: And obviously, there’s some urgency to this because the authorization runs out at the end of September and now we’re in July and they’re going to go away for August. So this is obviously something else that we’re going to need to keep a fairly close eye on. Well, meanwhile, elsewhere, as in at the Senate Finance Committee, which oversees Medicare and Medicaid, we’re starting to see legislation to regulate PBMs — pharmacy benefit managers — or are we? Rachel, we’ve come at this several times this year. How close are we getting?

Cohrs: We’re getting closer. And I think that two key committees are really feeling the heat to get their proposals out there before the end of the year. The first, like you mentioned, was the Senate Finance Committee, which is planning a markup next week, right before senators leave for August recess. They’ve asked for feedback from CBO [the Congressional Budget Office] around the end of August recess so that they’ll be ready to go. But I think it’s no secret that their delay in marking anything up or introducing anything has slowed down this process. And in the House, I know the Ways and Means Committee is trying to put together their own proposal and find time for a markup, whereas the House Energy and Commerce Committee, which also has jurisdiction over many of these issues, is frustrated, because they got their bill introduced, they had all the full regular order of subcommittee and then full committee hearings and then markups, got this bill unanimously out of their committee, and now everyone’s kind of waiting around on these two committees with jurisdiction over the Medicare program to see what they’re going to put together before any larger package can be compiled.

Rovner: Well, you know things are heating up when you start seeing PBM ads all over cable news. So even if you don’t understand what the issue is, you know that it’s definitely in play on Capitol Hill. Well, while we’re on the subject of drug prices, we have another lawsuit trying to block Medicare’s drug price negotiation, this one filed by Johnson & Johnson. Why so many? Wouldn’t these drug companies have more clout if they got together on one big suit, or is there some strategy here to spread it out and hope somebody finds a sympathetic judge?

Ollstein: Yes, I think the latter is exactly what they’re doing, because if they were to all kind of band together, then it would be putting all their eggs in one basket. And this way we see most of the companies have filed in different jurisdictions. I think Johnson & Johnson did file in the same court as Bristol Myers Squibb did, so I think it’s not a perfect trend. But generally what we are seeing is that the trade groups like the [U.S.] Chamber of Commerce and PhRMA [the Pharmaceutical Research and Manufacturers of America] kind of have their own arguments that they’re making in different venues. The drug manufacturers themselves have their own arguments that they’re making in their own venues, and they’re spreading out across the country in some typically more liberal courts and circuits and some more conservative. But I think that it’s important to note that the Chamber of Commerce so far is the only one that’s asked for a preliminary injunction, in Ohio. That is kind of the motion that, if it’s approved, could potentially put a stop to this program even beginning to go into effect. So they’ve asked for that by Oct. 1.

Rovner: And remember, I guess we’re supposed to see the first 10 drugs from negotiation in September, right?

Cohrs: By Sept. 1, yes.

Rovner: By Sept. 1.

Cohrs: Pretty imminently here.

Rovner: Also happening soon. Well, before we stop with the news this week, I do want to talk briefly about drug shortages. This has come up from time to time, both before and during the pandemic, obviously, when we had supply chain issues. But it seems like something new is happening. Some of these shortages seem to be coming because generic makers of some drugs just don’t find them lucrative enough to continue to make them. Now we’re looking at some major shortages of key cancer drugs, literally causing doctors to have to choose who lives and who dies. Are there any proposals on Capitol Hill for addressing this? It’s kind of flying below the radar, but it’s a pretty big deal.

Cohrs: I think we’ve seen Congressman Frank Pallone make this his pet issue in the reauthorization of PAHPA [Pandemic and All-Hazards Preparedness Act], which is the pandemic preparedness bill, which also expires on Sept. 30. So, you know, they have a full plate.

Rovner: Which we will talk about next week because they’re marking it up today.

Cohrs: Exactly. Yes. So but what we have seen is that Democrats in the House Energy and Commerce Committee have made this a top priority to at least have something on drug shortages in PAHPA. And I think my colleague John Wilkerson watched a hearing this week and noted that the chair of the committee, Cathy McMorris Rodgers, seemed more open to adding something than she had been in the past. But again, I think it’s kind of uncertain what we’ll see. And Sen. Bernie Sanders did add a couple of drug shortage policies to his version of PAHPA in the HELP Committee [Senate Committee on Health, Education, Labor and Pensions]. So I think we are seeing some movement on at least some policies to address it. But the problem is that the supply chain is not sexy and Republicans are not crazy about the idea of giving the FDA more authority. I think there is just so much skepticism of these public health agencies. It’s a hard systemic issue to crack. So I think we may see something, but it’s unclear whether any of this would provide any immediate relief.

Rovner: Everybody agrees that there’s a problem and nobody agrees on how to solve it. Welcome to Capitol Hill. OK, that is this week’s news. Now we will play my interview with Medicare chief Meena Seshamani, and then we’ll come back and do our extra credit. I am pleased to welcome to the podcast Meena Seshamani, deputy administrator and director of the Center for Medicare at the Centers for Medicare & Medicaid Services at the Department of Health and Human Services. That must be a very long business card.

Meena Seshamani: [laughs]

Rovner: Translated, that means she’s basically in charge of the Medicare program for the federal government. She comes to this job with more than the requisite experience. She is a physician, a head and neck surgeon in fact, a PhD health economist, a former hospital executive, and a former top administrator there at HHS. Meena, welcome to “What the Health?” We are so happy to have you.

Seshamani: Thank you so much for having me, Julie.

Rovner: So, our podcast listeners will know, because we talk about it so much, that the biggest Medicare story of 2023 is the launch of a program to negotiate prescription drug prices and hopefully bring down the price of some of those drugs. Can you give us a quick update on how that’s going and when patients can expect to start to see results?

Seshamani: Absolutely. The new prescription drug law, the Inflation Reduction Act, really has made historic changes to the Medicare program. And to your point, people are seeing those results right now. There is now a $35 cap on what someone will pay out-of-pocket for a month’s supply of covered insulin at the pharmacy, which is huge. I’ve met with people all over the country. Sometimes people are spending up to $400 for a month’s supply of this lifesaving medication. Also, vaccines at no cost out-of-pocket. And a lot of this leads to what you’re mentioning with the drug negotiation program, a historic opportunity for Medicare to negotiate drugs. In January, we put out a timeline of the various pieces that we’re putting in place to stand up this negotiation program. Along that timeline, we have released guidance that describes the process that we will undergo to negotiate, what we’ll think about as we’re engaging in negotiation. And the first 10 drugs for negotiation that are selected will be announced on Sept. 1. And that will then lead into the negotiation process.

Rovner: And as we’ve mentioned — I think it was on last week’s podcast — there’s a lot of lawsuits that are trying to stop this. Are you confident that you’re going to be able to overcome this and keep this train on the tracks?

Seshamani: Well, we don’t generally comment on the lawsuits. I will say that we are implementing this law in the most thoughtful manner possible. From the day that the law was enacted, we have been meeting with drug manufacturers, health plans, patient groups, health care providers, you know, experts in the field, to really understand the complexity of the drug space and what we can do with this opportunity to really improve things, improve access and affordability to have innovative therapies for the cures that people need.

Rovner: Well, while we are on that subject, we — not just Medicare, but society at large — is facing down a gigantic conundrum. The good news is that we’re finally starting to see drugs that can treat or possibly cure such devastating ailments as Alzheimer’s disease and obesity. But those drugs are currently so expensive, and the population that could benefit from them is so large, they could basically bankrupt the entire health care system. How is Medicare approaching that? Obviously, in the Alzheimer’s space, that could be a very big deal.

Seshamani: Well, Julie, we are committed to helping ensure that people have timely access to innovative treatments that can lead to improved care and better outcomes. And in doing this, we take into account what the Medicare law enables coverage for and what the evidence shows. So with Alzheimer’s, CMS underwent a national coverage determination. And consistent with that, Medicare is covering the drug when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world, also known as a registry. And this is very important because it will enable us to gather more information on patient outcomes as we continue to see innovations in this space. And you mentioned obesity. In the Medicare law, there is a carve-out for drugs for weight loss.

Rovner: A carve-out meaning you can’t cover them.

Seshamani: Correct. It says that the Medicare Part D prescription drug program will not cover drugs for weight loss. So we are looking at the increasing evidence. And for example, where there is a drug that is used for diabetes, for example, you know, then it can certainly be covered. And this is an area that we are continuing to partner with our colleagues in the FDA on and that we’d like to partner with the broader community to continue to build the evidence base around benefits for the Medicare population as we continue to evaluate where we want to make sure that people have access.

Rovner: But are you thinking sort of generally about what to do about these drugs that cost sometimes tens of thousands of dollars a year, hundreds of thousands of dollars a year, that half the population could benefit from? I mean, that cannot happen, right, financially?

Seshamani: Well, Julie, this is where the new provisions in the new drug law really come into play. Thinking from access for people for the high-cost drugs, I think we all know what a financial strain the high cost of drugs have created for our nation’s seniors, where now, in 2025, there will be a $2,000 out-of-pocket cap, that people will not have to pay out-of-pocket more than $2,000, which enables them to access drugs. And on the other side, as we talked about with drug negotiation, where for drugs that have been in the market for seven years or 11 years, if they are high-cost drugs, they could potentially be selected for negotiation where we can then, you know, as we laid out in the guidance that we put out, look at what is the benefit that this drug provides to a population? What are the therapeutic alternatives? And then also consider things like what’s the cost of producing that drug and distributing it? How much federal support was given for the research and development of that drug? And how much is the total R & D costs? So I think that there are several tools that we’ve been given in the Inflation Reduction Act that demonstrate how we are continuing to think about how we can ensure that Medicare is delivering for people now and in the future.

Rovner: Well, speaking of things that are popular but also expensive, let’s talk briefly about Medicare Advantage. More and more beneficiaries are opting for private plans over traditional, fee-for-service Medicare. But the health plans have figured out lots of ways to game the system to make large profits basically at taxpayers’ expense. Is there a long-term plan for Medicare Advantage or are we just going to continue to play whack-a-mole, trying to plug the loopholes that the plans keep finding?

Seshamani: You know, as now we have 50% of the population in Medicare Advantage, Medicare Advantage plays a critical role in advancing our vision for the Medicare program around advancing health equity, expanding access to care, driving innovation, and enabling us to be good stewards of the Medicare dollar. And that vision that we have is reflected in all of the policies that we have put forward to date. And I might add that those policies really have been informed by engagement with everyone who’s interested in Medicare Advantage. We did a request for comment and got more than 4,000 suggestions from people. This has now come out in recent policies like cracking down on misleading marketing practices so that people can get the plan that best suits their needs; ensuring clear rules of the road for prior authorization and utilization management so we can make sure that people are accessing the medically necessary care that they need; things like improving network adequacy, particularly in behavioral health, so people can access the health care providers in the networks of the plans; and then the work that we’re doing around payment, to make sure that we’re paying accurately, updating the years that we use for data, looking at the coding patterns of Medicare Advantage. And again, this is all work that is important to make sure that the program is really serving the people in the Medicare program.

Rovner: So, as you know, we’ve done big investigative projects here at KFF Health News about both medical debt and nonprofit hospitals not living up to their responsibilities to the community. As the largest single payer of hospitals, what is Medicare doing to try and address requirements for charity care, for example?

Seshamani: Well, the. IRS oversees the requirements for community benefit, which is how hospitals maintain or get a nonprofit status. We have certainly worked with the Consumer Financial Protection Bureau and the Department of Treasury on, for example, issuing a request for information, seeking public comment on, you know, medical credit cards. But even beyond that, I think this is an example of where we need to bring more payment accuracy and transparency in the health care system. So, for example, we have recently just proposed strengthening hospital price transparency so that people can know what is the cost of services, standard charges that hospitals provide. We also are adding quality measures to hospitals, particularly around issues around health equity, making sure that hospitals are screening patients for social needs. And we’re also tying increasingly our payment programs to making sure that those underserved populations are receiving excellent care, so again, really trying to drive transparency, quality, and access through all of the work that we’re doing with hospitals.

Rovner: But can you leverage Medicare’s power? Obviously, you know, that was what created EMTALA [the Emergency Medical Treatment and Labor Act], was leveraging Medicare’s power. Can you leverage it here to try and push some of these hospitals to do things they seem reluctant to do?

Seshamani: Where we have our levers in the Medicare program, we absolutely are working with hospitals around issues of equity, so as I mentioned, you know, really embedding equity not only in our quality requirements but also in hospital operations — for example, that as part of their operations they need to be looking at health equity. You know, where we are looking at how they are providing care and addressing issues of patient safety. So, we continue to look into all of these angles, and where we can support good practices. For example, we just proposed in our inpatient prospective payment system rule that when hospitals are taking care of homeless patients, that can be considered in their payment, because we have found through our analyses that additional resources are being used to make sure that those patients are supported for all of their needs, and we’re encouraging hospitals to code for these social needs so that we can continue to assess with them where resources and supports are needed to provide the kind of care that we all want for our populations.

Rovner: Last question, and I know that this is big, so it’s almost unfair. One of the reasons we know that it’s getting so expensive to manage medical costs is the increasing involvement of private equity in health care. What’s the Biden administration doing to address this growing profit motive?

Seshamani: Yeah, Julie, I’ll come back to, you know, what I alluded to before around transparency. We are really committed to transparency in health care, and we are continuing to focus on gathering data that sheds light on what is happening in the health care market so that we can be good stewards of the taxpayer dollar. So I mentioned our work in hospital price transparency, where we have streamlined the enforcement process; we have proposed to require standard ways that hospitals are reporting their charges and standard locations where they have to put a footer on the hospital’s homepage so that people can find that data easily. In Medicare Advantage, we are requiring more reporting for the medical loss ratio for plans to report spending on supplemental benefits like dental, vision, etc. And we really want to hone in on where else we can gather more data to be able to enable all of us to see what is happening in this dynamic health care market; what’s working? What isn’t? And so we’re very interested in getting ideas.from everyone of where more data can be helpful to enable us to then enact policies that can make sure that the health care industries and the market are really serving people in the most effective way possible.

Rovner: Well, you’ve got a very big job, so I will let you get back to it. Thank you so much, Meena Seshamani.

Seshamani: Thank you for having me.

Rovner: OK, we’re back and it’s time for our extra credit segment. That’s when we each recommend a story we read this week we think you should read too. As always, don’t worry if you miss it. We will post the links on the podcast page at kffhealthnews.org and in our show notes on your phone or other mobile device. Shefali, why don’t you go first this week?

Luthra: Sure. So mine is from KFF Health News by a dream team, Bram Sable-Smith, Daniel Chang, Jazmin Orozco Rodriguez, and Sandy West. The headline is “Medical Exiles: Families Flee States Amid Crackdown on Transgender Care.” And I mean, it’s exactly what it sounds like. It’s this really person-grounded, quite deeply reported story about how restrictions on gender-affirming health care, especially for young people, are forcing families to leave their homes. And this is a really tough thing for people to do, you know, leave somewhere where you’ve lived for 10 years or longer and go somewhere where you don’t have ties. Moving is quite expensive. And I think this is a really important look at something that we anecdotally know is happening, haven’t seen enough really great deep dives on, and is something that potentially will happen more and more as people are forced to leave their homes if they can afford to do so because they don’t feel safe there anymore.

Rovner: Yeah, and this is the issue of doing these social issues state by state by state, just what’s happening now. Alice.

Ollstein: So I chose a piece from The Atlantic called “What Happened When Oregon Decriminalized Hard Drugs,” by Jim Hinch. It was really fascinating. On the one side, they say this is evidence that the policy has failed, that decriminalizing possession of small amounts of cocaine, heroin, all hard drugs, has been a failure because overdoses have actually gone up since then. But other experts quoted in this article say that, look, we tried the punitive war on drugs model for decades and decades and decades before declaring it a failure; how can we evaluate this after just a few years? It just takes more time to make this transition and takes more time to, you know, ramp up treatment and services for people, and because this happened three years ago, it was disrupted by the pandemic and, you know, services were not able to reach people, etc. So a really fascinating look.

Rovner: Yes, it’s quite the social experiment that’s going on in Oregon. Rachel.

Cohrs: So mine is from The New York Times, a group of reporters and a new series called “Operating Profits.” And the headline is “They Lost Their Legs. Doctors and Health Care Giants Profited.” And I think I’m just really excited to see more about this line of reporting about overutilization in health care and how certain payment incentives — I mean, they made a story about payment incentives in hospital outpatient departments and how pay rates change really personal and interesting, and it’s important. So, I mean, all these really dense rules that we’re seeing drop this summer do really have implications for patients. And there are bad actors out there who are kind of capitalizing on that. So I felt it was like really responsible reporting, mostly focused on one physician who, you know, was doing procedures that he shouldn’t have and other doctors ultimately were left to clean up the damage for these patients. And they had amputations that they maybe shouldn’t have had, which is such a serious and devastating consequence. I thought that was very important reporting, and I’m excited to see what’s next.

Rovner: Yeah, I’m looking forward to seeing the rest of the series. Well, my story this week is in the Los Angeles Times from my KFF Health News colleague Noam Levey, who’s been working on a giant project on medical debt. It’s called “Crushing Medical Debt Is Turning Americans Against Their Doctors.” And it points out something I hadn’t really thought about before, that outrageous and unexpected bills are undermining public confidence in medical providers and the medical system writ large. And so far, nobody’s doing very much about it. To quote from Noam’s piece, “Hospitals and doctors blame the government for underpaying them and blame insurers for selling plans with unaffordable deductibles. Insurers blame providers for obscene prices. Everyone blames drug companies.” Well, it’s going to take a lot of time to dig out of this hole, but probably it would help if everybody stopped digging. OK. That is our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review; that helps other people find us too. Special thanks, as always, to our producer, Francis Ying. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m still @jrovner, and I’m on Threads @julie.rovner. Shefali.

Luthra: I’m @shefalil.

Rovner: Alice.

Ollstein: @AliceOllstein.

Rovner: Rachel.

Cohrs: I’m @rachelcohrs.

Rovner: We will be back in your feed next week. Until then, be healthy.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ ‘What the Health?’ on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

The Host

Julie Rovner
KFF Health News

@jrovner

Read Julie's stories.

Julie Rovner is chief Washington correspondent and host of KFF Health News’ weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A to Z,” now in its third edition.

In this special episode of KFF Health News’ “What the Health?” host and chief Washington correspondent Julie Rovner leads a rare conversation with the current and two former secretaries of Health and Human Services. Taped before a live audience at Aspen Ideas: Health, part of the Aspen Ideas Festival, in Aspen, Colorado, Secretary Xavier Becerra and two of his predecessors, Kathleen Sebelius and Alex Azar, talk candidly about what it takes to run a department with more than 80,000 employees and a budget larger than those of many countries.

Among the takeaways from this week’s episode:

• The Department of Health and Human Services is much more than a domestic agency. It also plays a key role in national security, the three HHS secretaries explained, describing the importance of the “soft diplomacy” of building and supporting health systems abroad.
• Each HHS secretary — Sebelius, who served under former President Barack Obama; Azar, who served under former President Donald Trump; and Becerra, the current secretary, under President Joe Biden — offered frank, sobering, and even funny stories about interacting with the White House. “Anything you thought you were going to do during the day often got blown up by the White House,” Sebelius said. Asked what he was unprepared for when he started the job, Azar quipped: “The Trump administration.”
• Identifying their proudest accomplishment as the nation’s top health official, Azar and Becerra both cited their work responding to the covid-19 pandemic, specifically Operation Warp Speed, the interagency effort to develop and disseminate vaccines, and H-CORE, which Becerra described as a quiet successor to Warp Speed. They also each touted their respective administrations’ efforts to regulate tobacco.
• Having weathered recent debates over the separation of public policy and politics at the top health agency, the panel discussed how they’ve approached balancing the two in decision-making. For Becerra, the answer was unequivocal: “We use the facts and the science. We don’t do politics.”

Click to open the transcript

Transcript: Live From Aspen: Three HHS Secretaries on What the Job Is Really Like

KFF Health News’ ‘What the Health?’

Episode Title: Live From Aspen: Three HHS Secretaries on What the Job Is Really Like

Episode Number: 303

Published: June 22, 2023

[Editor’s note: This transcript, generated using transcription software, has been edited for style and clarity.]

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, coming to you this week from the Aspen Ideas: Health conference in Aspen, Colorado. We have a cool special for you this week. For the first time, the current secretary of Health and Human Services sat down for a joint interview with two of his predecessors. This was taped before a live audience on Wednesday evening, June 21, in Aspen. So, as we like to say, here we go.

Hello. Good evening. Welcome to Aspen Ideas: Health. I’m Julie Rovner. I’m the chief Washington correspondent for KFF Health News and also host of KFF Health News’ health policy podcast, “What the Health?,” which you are now all the audience for, so thank you very much. I’m sure these people with me need no introduction, but I’m going to introduce them anyway because I think that’s required.

Immediately to my left, we are honored to welcome the current U.S. secretary of Health and Human Services, Xavier Becerra. Secretary Becerra is the first Latino to serve in this post. He was previously attorney general of the state of California. And before that, he served in the U.S. House of Representatives for nearly 25 years, where, as a member of the powerful Ways and Means Committee, he helped draft and pass what’s now the Affordable Care Act. Thank you for joining us.

Next to him, we have Kathleen Sebelius, who served as secretary during the Obama administration from 2009 to 2014, where she also helped pass and implement the Affordable Care Act. I first met Secretary Sebelius when she was Kansas’ state insurance commissioner, a post she was elected to twice. She went on to be elected twice as governor of the state, which is no small feat in a very red state for a Democrat. Today, she also consults on health policy and serves on several boards, including — full disclosure — that of my organization, KFF. Thank you so much for being here.

And on the end we have Alex Azar, who served as HHS secretary from 2018 to 2021 and had the decidedly mixed privilege of leading the department through the first two years of the covid pandemic, which I’m sure was not on his to-do list when he took the job. At least Secretary Azar came to the job with plenty of relevant experience. He’d served in the department previously as HHS deputy secretary and as general counsel during the George W. Bush administration and later as a top executive at U.S. drugmaker Eli Lilly. Today, he advises a health investment firm, teaches at the University of Miami Herbert Business School, and sits on several boards, including the Aspen Institute’s. So, thank you.

Former Secretary of Health and Human Services Alex Azar: Thank you.

Rovner: So I know you’re not here to listen to me, so we’re going to jump in with our first question. As I’m sure we will talk about in more detail, HHS is a vast agency that includes, just on the health side, agencies including the Food and Drug Administration, the National Institutes of Health, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services. The department has more than 80,000 employees around the country and throughout the world and oversees more than one and a half trillion dollars of federal funding each year. I want to ask each of you — I guess we’ll start with you — what is the one thing you wish the public understood about the department that you think they don’t really now?

Secretary of Health and Human Services Xavier Becerra: Given everything you just said, I wish people would understand that the Constitution left health care to the states. And so, as big as we are and as much as we do — Medicare, Medicaid, CHIP [Children’s Health Insurance Program], Obamacare — we still don’t control or drive health care. The only way we get in the game is when we put money into it. And that’s why people do Medicare, because we put money into it. States do Medicaid because we put money into it. And it became very obvious with covid that the federal government doesn’t manage health care. We don’t have a national system of health or public health. We have a nationwide system of public health where 50 different states determine what happens, and so one state may do better than another, and we’re out there trying to make it work evenhandedly for everyone in America. But it’s very tough because we don’t have a national system of public health.

Rovner: Secretary, what’s the thing that you wish people understood about HHS?

Former Secretary of Health and Human Services Kathleen Sebelius: Well, I agree with what Secretary Becerra has said, but it always made me unhappy that people don’t understand fully, I don’t think, the international role that HHS plays, and it is so essential to the safety and security and resilience of the United States. So we have employees across the world. CDC has employees in about 40 other countries, and helping to build health systems in various parts of the world, sharing information about how you stand up a health system, what a great hospital looks like. NIH does experiments and clinical trials all over the globe and is regarded as the gold standard. And we actually, I think, at HHS were able to do what they call soft diplomacy. And a lot of countries aren’t eager to have the State Department involved. They’re certainly not eager to see soldiers. Our trade policies make some people uncomfortable. But they welcome health professionals. They welcome the opportunity to learn from the United States. So it’s really a way often to get into countries and make friendships. And we need to monitor across the globe, as covid showed so well. When an outbreak happens someplace else in the world, we can’t wait for it to arrive on the border of the United States. Safety and security of American citizens really depends on global information exchange, a global surveillance exchange. The CDC has also trained epidemiologists in regions around the world so that they can be faster and share information. And I think too often in Congress, those line items for foreign trips, for offices elsewhere, people say, “Well, we don’t really need that. We should focus all our attention on America.” But I’ve always thought, if folks really understood how integral it is not just to our health security, but really national security, that we have these partnerships — and it’s, as I say, I think the best soft diplomacy and the cheapest soft diplomacy underway is to send health professionals all over the globe and to make those friendships.

Rovner: Do you think people understand that better since covid?

Sebelius: Maybe. You know, but some people reacted, unfortunately, to covid, saying, “Well, we put up bigger walls, and we” — I mean, no disease needs a passport, no wall stops things from coming across our borders. And I’m not sure that still is something that people take to heart.

Rovner: Secretary Azar, you actually have the most — in terms of years — experience at the department. What is it that people don’t know that they should?

Azar: So I probably would have led with what Secretary Becerra said about just how highly decentralized the public health infrastructure and leadership and decision-making is in the United States. I mean, it really — all those calls are made, and it’s not even just the 50 states. It’s actually 62 public health jurisdictions, because we separately fund a whole series of cities. I’ll concur in that. I’d say the other thing that people probably don’t understand, and maybe this is too inside baseball, is the secretary of HHS is, on the one hand, probably the most powerful secretary in the Cabinet and, on the other hand, also quite weak. So literally every authority, almost every authority, in the thousands and thousands of pages of U.S. statute that empower programs at HHS, say, “The secretary shall …” So the FDA, the CDC, CMS, all of these programs really operate purely by delegation of the secretary, because Secretary Becerra allows them to make decisions or to run programs. They are his authorities. And so the media, then, when the secretary acts, will … [unintelligible] … “How dare you,” you know, “how dare you be involved in this issue or that issue?” Well, it is legally and constitutionally Secretary Becerra’s job. And, on the other hand, you are supervising — it’s like a university, because you’re also supervising operating divisions that are global household brands. It is really like being a university president, for all that’s good and evil of that. You have to lead by consensus. You have to lead by bringing people along. You are not a dictator, in spite of what the U.S. statutes say. It’s very, very similar to that — that you, the secretary, is both powerful, but also has to really lead a highly matrixed, consensus-based organization to get things done.

Rovner: You’re actually leading perfectly into my next question, which is, how do you juggle all the moving pieces of this department? Just putting the agency heads in one room could fill a room this size. So tell us what sort of an average day for each of you would look like as secretary, if there’s such a thing as an average day.

Azar: Well, first, not an average administration, so take with a grain of salt my average day. So, interspersed among the two to five phone calls with the president of the United States between 7 a.m. and midnight, you know, other than that, um — I started every day meeting with my — you know, as secretary, you’ve got to have a team around you that’s not just your operating divisions, but I would start every morning — we would have just a huddle with chief of staff, deputy chief of staff, my head of public affairs. Often my general counsel would join that, my legislative leader. Just what’s going to hit us in the face today? Like, what are we trying to do, and what’s going to hit us in the face today? Just a situational awareness, every morning at about 8 a.m., quick huddle on that, and then diving into really the rhythm of the day of — I tried to drive — I use a book that I helped actually do some of the work on called “The 4 Disciplines of Execution,” just a tool of how do you focus and drive change in very complex organizations? So I tried to focus on four key initiatives that I spent as much of my time as secretary on leading and pushing on, and so I tried to make sure as much of my time was doing that. But then it’s reactive. You’re having to go to White House meetings constantly. You have to sign off on every regulation at the department. And so you’re in meetings just getting briefed and deciding approve or disapprove, so that rhythm constantly, and then add travel in, add evening commitments, add speeches. I’d say the biggest challenge you have as a leader in HHS is that first point of, focus, because you could be like a bobber on the water, just going with whatever’s happening, if you don’t have a maniacally focused agenda of, “I’ve got a limited amount of time. I’m going to drive change here. And if I don’t spend time every day pushing the department on this issue, being basically a burr in the saddle to make it happen, it won’t.” And you’ve just got to constantly be on that.

Rovner: Secretary Sebelius, what did your average day look like?

Sebelius: Well, I’m not going to repeat what Alex has just said. A lot of that goes on in the daily routine. First of all, I think all of us would be sent home the night before with a binder of materials — briefings for what you’re going to do the next day. So you may have 10 meetings, but each of those has a 20-page brief behind it. And then what the issues are, what the questions might be. So that’s your homework often that you’re leaving with at 7 or 8 at night. I like to run in the morning, and I would get up, read my schedule, and then go out and run on the [National] Mall because it sort of cleared my head. I’m proud of having — some of the folks may still be here — none of the detail ran before I started running, and my deal with them was, “I’m much older than you are, you know. We’re all going to run.”

Azar: They still —

Sebelius: Oh, here we go.

Azar: They still talk about it.

Sebelius: Well, one of them got to be a great marathon runner, you know. Can’t hurt. One guy started riding a bike, and I was like, “What are you doing?” I mean, if I fall, what are you going to do with the bike? I mean, am I going to carry it, are you going to carry it? I mean, who — anyway, so I started that way. You’d go then into the office. And one of the things that was not mentioned is HHS has an amazing, camera-ready studio, TV studio, that lots of other Cabinet agencies used. It has a setting that looks like “The View.” It has a stool that you can look in cameras, but two or three days a week we would do what they call “Around the Country.” So you would sit in a stool, and I’d be doing updates on the ACA or a pitch to enrollment or something about a disease, and you would literally have a cue card up that would say “Minneapolis, Andrea.” And I would say, “Good morning, Andrea.” And we would do a two-second spot in Minneapolis and they’d have numbers for me and then the camera would switch and it would be Bob in St. Louis. “Hello, Bob. How are you?” So that was a morning start that’s a little bit different. Anything you thought you were going to do during the day often got blown up by the White House: somebody calling, saying, you know, “The president wants this meeting,” “the vice president’s calling this.” So then the day gets kind of rearranged. And I think the description of who the key staff are around, but 12 operating agencies — any one of them could be a much more than full-time job. So just getting to know the NIH or, you know, seeing what CDC in Atlanta does every day, but trying to keep the leadership in touch, in tune, and make sure that — one of the things that, having been a governor and working with Cabinet agencies, that I thought was really important, is everybody has some input on everything. These are the stars, the agency heads. They know much more about health and their agencies than I would ever know. But making sure that I have their input and their lens on every decision that was made. So we had regular meetings where the flatter the organization, the better, as far as I’m concerned. They were all there and they gave input into policy decisions. But it is not a boring job and it’s never done. You just had to say at the end of the day, with this giant book, “OK, that’s enough for today. I’ll start again tomorrow, and there’ll be another giant book and here we go.”

Rovner: And your day, since you’re doing it now?

Becerra: I don’t know if it’s the pleasure or the bane of starting off virtually. Almost everything we did was via Zoom. I didn’t meet many of my team until months into the term because we were in the midst of covid. So we would start the days usually pretty early in the morning with Zooms and it would go one Zoom after the other. Of course, once we started doing more in-person activities, schedulers still thought they could schedule you pretty much one right after the other, and so they pack in as much as they can. I think all of us would say we’re just blessed to have some of the most talented people. I see Commissioner Califf from the FDA over there in the room. I will tell you, it’s just a yes … [applause] … . It’s a blessing to get to serve with these folks. They are the best in their fields. And you’re talking about some pretty critical agencies, FDA, NIH, CDC, CMS. I mean, the breadth, the jurisdiction, of CMS is immense. They do fabulous work. They are so committed. And so it makes it a lot easier. And then, of course, we all — we each have had — I have my group of counselors who are essentially my captains of the different agencies, and they help manage, because without that it would be near-impossible. And these are people who are younger, but my God, they’re the folks that every CEO looks for to sort of help manage an agency, and they’re so committed to the task. And so I feel like a kid in a candy store because I’m doing some of the things that I worked on so long when I was a member of Congress and could never get over the finish line. Now I get to sort of nudge everything over the finish line, and it really is helpful, as Alex said, to remind people that the statute does say, “The secretary shall … ,” not someone else, “the secretary shall … .” And so, at the end of the day, you get to sort of weigh it. And so it’s a pleasure to work with very talented, committed people.

Sebelius: Julie, I want to throw in one more thing, because I think this is back to what people don’t know, but it’s also about our days. There’s an assumption, when administrations change, the whole agency changes, right? Washington all changes. In a department like HHS, 90,000 employees scattered in the country and around the world, there are about 900 total political appointees, and they are split among all the agencies and the secretary’s office there. So you’re really talking about this incredibly talented team of professionals who are running those agencies and have all the health expertise, with the few people across the top that may try to change directions and put — but I think there’s an assumption that sort of the whole group sweeps out and somebody else sweeps in, and that really is not the case.

Rovner: So, as I mentioned, all three of you had relevant government experience before you came to HHS. Secretary Sebelius, you were a governor, so you knew about running a large organization. I want to ask all three of you, did you really understand what you were getting into when you became secretary? And is there some way to grow up to become HHS secretary?

Azar: I mean, yeah, I — yeah, I have no excuse. My first day, right after getting sworn in — the secretary has a private elevator that goes directly up to the sixth floor where the suite is, the deputy secretary’s office to the right, secretary to the left — my first day, I’m up, headed up with my security detail, and I get off and I walk off to the right. “Mr. Secretary, no, no, no. It’s this way.” Literally, it was like — it had been 11 years, but it was like coming home to me. I was literally about to walk into my old office as deputy secretary, and they show me to the secretary’s office. And I think for the first three months, I kept thinking Tommy Thompson or Mike Leavitt was going to walk in and say, “Get the hell out of my office.” And no, so it, and it was the same people, as Secretary Sebelius said. I knew all the top career people. I’d worked with them over the course of — in and out of government — 20 years. So it was very much a “coming home” for me. And it was many of the same issues were still the same issues. Sustainable growth rate — I mean, whatever else, it was all the same things going on again, except the ACA was new. That was a new nice one you gave me to deal with also. So, yeah, thank you.

Sebelius: You’re welcome. We had to have something new.

Rovner: What were you unprepared for when you took on this job?

Azar: Well, for me, the Trump administration.

Rovner: Yeah, that’s fair.

Azar: I, you know, had come out of the Bush administration. You’re at Eli Lilly. I mean, you know, you’re used to certain processes and ways people interact. And, you know, it’s just — it was different.

Sebelius: I had a pretty different experience. The rhythm of being a governor and being a Cabinet secretary is pretty similar. Cabinet agencies, working with the legislative process, the budget. So I kind of had that sense. I had no [Capitol] Hill experience. I had not worked on the Hill or served on the Hill, so that was a whole new entity. You’re not by protocol even allowed in the department until you’re confirmed. So I had never even seen the inside of the office. I mean, Alex talked about being confused about which way to turn. I mean, I had no idea [about] anything on the sixth floor. I hadn’t ever been there. My way of entering the department — I was President [Barack] Obama’s second choice. [Former South Dakota Democratic Senator] Tom Daschle had been nominated to be HHS secretary. And that was fine with me. And I said, “I’m a governor. I’ve got two more years in my term. I’ll join you sometime.” And then when Sen. Daschle withdrew, the president came back to me and said, “OK, how about, would you take this job if you’re able to get it?” And I said, “Yes, that’s an agency that’s interesting and challenging.” So I still was a governor, so I was serving as governor, flying in and out of D.C. to get briefings so I could go through hearings on this department that I didn’t know a lot about and had never really worked with, and then would go back and do my day job in Kansas. And the day that the Senate confirmation hearing began, a call came to our office from the White House. And this staffer said, “This governor? “Yes.” “President Obama has a plane in the air. It’s going to land at Forbes Air Force Base at noon. We want you on the plane.” And I said, you know, “That’s really interesting, but I don’t have a job yet. And I actually have a job here in Kansas. And here’s my plan. You know, my plan is I’m going to wait until I get confirmed and then I’ll resign and then I’ll get on the plane and then I’ll come to D.C.” And they said, “The president has a plane in the air, and it will land. He wants you on the plane.” First boss I’d had in 20 years. And I thought, “Oh, oh, OK. That’s a new thing.” So I literally left. Secretary Azar has heard this story earlier, but I left an index card on my desk in Kansas that said, “In the event I am confirmed, I hereby resign as governor.” And it was notarized and left there because I thought, I’m not giving up this job, not knowing if I will have another job. But halfway across the country I was confirmed and they came back and said — so I land and I said, “Where am I going?” I, literally, where — I mean, I’m all by myself, you know, it’s like, where am I going? “You’re going to the White House. The president’s going to swear you in.” “Great.” Except he couldn’t swear me in. He didn’t have the statutory authority, it turns out, so he could hold the Bible and the Cabinet secretary could swear me in. And then I was taken to the Situation Room, with somebody leading the way because I’d never been to the Situation Room. And the head of the World Health Organization was on the phone, the health minister from Canada, the health minister from Mexico, luckily my friend Janet Napolitano, who was Department of Homeland Security secretary — because we were in the middle of the H1N1 outbreak, swine flu, nobody knew what was going on. It was, you know, an initial pandemic. And everybody met and talked for a couple of hours. And then they all got up and left the room and I thought, woo-hoo, I’m the Cabinet secretary, you know, and they left? And somebody said to me later, well, “Does the White House find you a place to live?” I said, “Absolutely not. Nobody even asked if I had a place to stay.” I mean, it was 11 o’clock at night. They were all like, “Good night,” “goodbye,” “see ya.” So I luckily had friends in D.C. who I called and said, “Are you up? Can I come over? I’d like somebody to say, ‘Yay,’ you know, ‘we’re here.’” So that’s how I began.

Rovner: So you are kind of between these two. You have at least a little more idea of what it entailed. But what were you unprepared for in taking on this job?

Becerra: Probably the magnitude. Having served in Congress, I knew most of the agencies within HHS. I had worked very closely with most of the bigger agencies at HHS. As AG — Alex, I apologize — I sued HHS quite a —

Azar: He sued me a lot.

Becerra: Quite a few times.

Azar: Becerra v. Azar, all over the place.

Becerra: But the magnitude. I thought running the largest department of justice in the land other than the U.S. Department of Justice was a pretty big deal. But then you land and you have this agency that just stretches everywhere. And I agree with everything that Kathleen said earlier about the role that we play internationally. We are some of the best ambassadors for this country in the world because everyone wants you to help them save lives. And so it really helps. So the magnitude — it just struck me. When President Biden came in, we lost the equivalent of about — what, 13 9/11 twin tower deaths one day. Every day we were losing 11 twin tower deaths. And it hits you: You’ve got to come up with the answer yesterday. And so the White House is not a patient place, and they want answers quickly. And so you’re just, you’re on task. And it really is — it’s on you. You really — it smothers you, because you can’t let it go. And whether it was covid at the beginning or monkeypox last year, all of a sudden we see monkeypox, mpox, starting to pop up across the country. And it was, could this become the next covid? And so right away you’ve got to smother it. And the intensity is immediate. Probably the thing that I wasn’t prepared for as well, along with the magnitude, was, as I said, the breadth. Came in doing all these Zooms virtually to try to deal with the pandemic. But probably the thing that I had to really zero in on even more, that the president was expecting us to zero in on more, was migrant kids at the border and how you deal with not having a child sleep on a cement floor with an aluminum blanket and just trying to deal with that. It won’t overwhelm you necessarily, but — and again, thank God you’ve got just people who are so committed to this, because at any hour of the day and night, you’re working on these things — but the immensity of the task, because it’s real. And other departments also have very important responsibilities — clearly, Department of Defense, Department of State. But really it truly is life-and-death at HHS. So the gravity, it hits you, and it’s nonstop.

Rovner: All three of you were secretary at a time when health was actually at the top of the national agenda — which is not true. I’ve been covering HHS since 1986, and there have been plenty of secretaries who sort of were in the back of the administration, if you will, but you all really were front and center in all of these things. I want to go to sort of down the line. What was the hardest decision you had to make as secretary?

Becerra: Um …

Rovner: You’re not finished yet. I should say so far.

Becerra: I mean, there have been a lot of tough decisions, but, you know, when your team essentially prepares them up and you have all this discussion, but by the time it gets to me, it really has been baked really, really well. And now it’s sort of, White House is looking at this, we are seeing some of this, we’ve got to make a call. And again, Dr. Califf could speak to this as well. At the end of the day, the decisions aren’t so much difficult. It’s that they’re just very consequential. Do you prepare for a large surge in omicron and therefore spend a lot of money right now getting ready? Or do you sort of wait and see a little bit longer, preserve some of your money so you can use some of that money to do the longer-term work that needs to be done to prepare for the next generation of the viruses that are coming? Because once you spend the dollar, you don’t have it anymore. So you got to make that call. Those are the things that you’re constantly dealing with. But again, it just really helps to have a great team.

Sebelius: So I would say I was totally fortunate that the pandemic we dealt with was relatively short-lived and luckily far, far milder than what consumed both the secretaries to my left and right, and that was fortunate. A lot of our big decision areas were under the rubric of the Affordable Care Act and both trying to get it passed and threading that needle but then implementation. And I — you know, thinking about that question, Julie, I would say one of the toughest decisions — just because it provided a real clash between me and some of the people in the White House; luckily, at the end of the day, not the president, but — was really about the contraception coverage. Reproductive health had been something I’d worked on as a legislator, as governor. I felt very strongly about it. We’d fought a lot of battles in Kansas around it, and part of the Affordable Care Act was a preventive services benefit around contraceptive care. And that was going to be life-changing for a lot of women. And how broad it should be, how many battles we were willing to take on, how that could be implemented became a clash. And I think there were people in the administration who were hopeful that you could avoid clashes. So just make a compromise, you know, eliminate this group or that group, who may get unhappy about it. And at the end of the day, I was helped not just by people in the department, but mobilized some of my women Cabinet friends and senior White House women friends. And we sort of had a little bit of a facedown. And as I say, the president ended up saying, “OK, we’ll go big. We’ll go as big as we possibly can.” But I look back on that as a — I mean, it was a consequential decision, and it was implementation — not passing the rag in the first place, but implementing it. And it had a big impact. A big impact. It’s not one I regret, but it got a little a little tense inside, but what would be friendly meetings.

Azar: I’d use the divide Secretary Becerra talked about, which is that consequential versus hard decisions, that a lot — I think one could have a Hamlet-like character. I don’t. And so making the call when it comes to you wasn’t a terribly difficult thing, even. These are life-and-death decisions, but still yourself, you know your thought processes, you think it through, it’s been baked very well, you’ve heard all sides. You just have to make that call. So I’d maybe pivot to probably it’s more of a process thing. The hardest aspect for me was just deciding when do you fight and when do you not fight with, say, the White House? What hills do you die on? And where do you say, “Yeah, not what I would do, but I just have to live to fight another day.” Those were probably the toughest ones to really wrestle with.

Rovner: Was there one where you really were ready to die on the hill?

Azar: There were a lot. There were a lot. I mean, I’ll give you one example. I mean, I left a lot of blood on the field of battle just to try to outlaw pharmaceutical rebates, to try to push those through to the point of sale. I probably stayed to the end just to get that dag — because I, the opponents had left the administration and I finally got that daggone rule across the finish line right at the end. And that was something that I felt incredibly strongly that you could never actually change. I’ve lived inside that world. You could never change the dynamic of pharmaceutical drug pricing without passing through rebates to the point of sale. And I had so many opponents to get that done. It was a three-year constant daily battle that felt vindicated then to get it done. But that was a fight.

Rovner: And of course, I can’t help but notice that all of the things that you all are talking about are things that are still being debated today. None of them are completely resolved. Let’s turn this around a little bit. I wanted to ask you what you’re most proud of actually getting accomplished. Was it the rebate rule? That was a big deal.

Azar: For me, it has to be Operation Warp Speed. …[applause] … Yeah. Thank you. That was just — I mean, and I don’t want to take the credit. I mean, it was public-private. Mark Esper, this could not have happened without the partnership of the Defense Department, and it could not have happened without Mark Esper as secretary, because — I guarantee you, I’ve dealt with a lot of SecDefs in my career — and when the secretary of defense says to you, “Alex, you have the complete power and support of the Department of Defense. You just tell me what you need.” I haven’t heard those words before. And he was a partner and his whole team a partner throughout. And when you have the muscle of the U.S. military behind you to get something done, it is miraculous what happens. I mean, we were making hundreds of millions of doses of commercial-scale vaccine in June of 2020, when we were still in phase 2 clinical trials. We were just making it at risk. So we’re pumping this stuff out. And in one of the factories, a pump goes down. The pump is on the other side of the country on a train. The U.S. military shoots out a fighter jet, it gets out there, stops the train, pulls the train over, puts it on a helicopter, gets it on the jet, zips it off to the factory. We have colonels at every single manufacturing facility, and they get this installed. We’re up and running within 24 hours. It would have taken six to nine months under normal process. But the U.S. military got that done. So that for me was like just — the other two quick, one was banning flavored e-cigarettes. We got 25% reduction in youth use of tobacco in 12 months as a result of that. And then one of the great public health victories that this country had and the world had got ignored because it got concluded in June of 2020: We had the 11th Ebola outbreak. It was in the war zone in the eastern Democratic Republic of the Congo. This was the pandemic I was really, really worried about. One-hundred seventy-four warring groups in the war zone in the eastern Congo. Got [WHO Director-General] Tedros [Adhanom Ghebreyesus] and [then-Director of the National Institute of Allergy and Infectious Diseases Anthony] Fauci and [then-CDC Director Robert] Redfield, and we went over and we went on the ground and we got that. And by June of 2020, that one got out, which was a miracle of global public health. I’m with Kathleen on that one; I think global public health is a key instrument of American power projection humanity around the world. Sorry to go so long.

Rovner: It’s OK. Your turn.

Sebelius: I think proudest is the ability to participate in the Affordable Care Act and push that over the finish line. And for me, it was a really personal journey. My father was in Congress and was one of the votes for Medicare and Medicaid to be passed, so that chunk of the puzzle. I was the insurance commissioner in Kansas when the Republican governor asked me to do the implementation of the Children’s Health Insurance Program. So I helped with that piece. I was on President [Bill] Clinton’s patient protection commission and ended up with a lot of that package in the Affordable Care Act. And then finally to work for and support and watch a president who basically said when he announced for president, “This is my priority in my first term: I want to pass a major health care bill.” And a lot of people had made that pledge. But 15 months later, there was a bill on his desk and he signed it, and we got to implement it. So that was thrilling. Yeah. And, I should tell you, then-Congressman Becerra was one of the wingmen in the House who I worked with carefully, who — there was no better vote counter than Nancy Pelosi, but by her side was this guy, part of her delegation, named Xavier Becerra, who was whipping the votes into place. So he played a key role in making sure that crossed the finish line.

Becerra: So I’m still here, so you’re going to have to —

Rovner: You can change your answer later.

Becerra: I need a bit of grace here, because I’m going to start with Warp Speed, because I bet no one here knows there’s no longer a Operation Warp Speed. It’s now called H-CORE. And the reason I’m very proud of that is because you don’t know that it’s now H-CORE. And what makes it such a good thing is that the Department of Defense no longer has any role in the protection of the American people from covid. It’s all done in-house at HHS. Everything used to be done essentially under the auspices of the Department of Defense, because they are just the folks that can get things done in 24 hours. We do that now, and it’s the operations that were begun a while back. Kathleen had them, Alex had them. Our ASPR, that’s our Preparedness and Response team, they’re doing phenomenal work, but you don’t know it, and you don’t know that H-CORE took to flight in the first year of the Biden administration. By December of 2021, Department of Defense had transferred over all those responsibilities to us, and we’ve been doing it since. But if you ask me what am I most proud of, it’s, I mean, there are more Americans today than ever in the history of this country who have the ability to pay for their own health care because they have health insurance, more than 300 million. Part of that is Obamacare; a record number, 16 and a half million Americans, get their insurance through the marketplaces, and we haven’t stopped yet. There are close to 700 million shots of covid vaccine that have gone into the arms of Americans. That’s never been done in the history of this country. Some of you are probably familiar with three digits, 988, at a time when Americans are … [applause] … 9 in 10 Americans would tell you that America is experiencing a mental health crisis, especially with our youth. And Congress got wise and said, instead of having in different parts of the country, based on region, you could call a phone number for a suicide lifeline, if you didn’t know the 10-digit number or what part of the country you were in, you were out of luck — today, all you have to do is dial 988. But as I said before, federal government doesn’t run mental health. It’s all done by the states. But President Biden is very committed to mental health. His budgets have surpassed any type of investments that have been called for by any president in history for mental health. And he was very committed to 988 to make sure it launched right. And so we have, by exponential numbers, put money into 988 to make sure every state was ready to have it launch. And so by July of 2022, we launched 988, and it is working so well that people are actually calling — actually, not just calling. We now have a text feature and a chat feature because surprise, surprise, young people prefer not to call; they actually prefer to text. And we have increased the number of Americans who are reaching out by over 2 million, which is great, but it’s also not great because it shows you how much Americans are hurting. So there’s so many things I can tell you that I feel very good about that we’re doing. We’re not done. We’re moving beyond on tobacco where Alex left. We’re now moving to ban menthol in cigarettes. Menthol cigarettes are the most popular brand of cigarettes in America. They hook you because of the menthol, and we’re moving to extract menthol. We’re moving to ban flavored cigars and cigarillos. And we may be on course to try to see if we can move to extract as much nicotine out of tobacco as possible before it becomes a product on the market for folks to smoke. So we’re doing a whole lot of things there. And obviously on vaping, e-cigarettes as well — and Dr. Califf could mention that. But I’ll say the thing I’m probably most proud of is that, out of all the government agencies in America, federal government agencies, HHS ranks No. 2 as the best place to work. And I will tell you we’re No. 2, because if we had the capacity to tell our workforce, we will fly you to the moon and back the way NASA does, we’d be No. 1. So that’s what I think I’m most proud of, is that people, as hard as we work them, still say, “Come work at HHS.”

Rovner: So all of you have mentioned these things that were really hard to do because of politics. And you’ve all talked about how some of these decisions, when they get to you, have been baked by your staff and, you know, they vetted it with every side. But I think the public feels like politics determine everything. And I think you all would like to think that policy is what helps determine most things. So, what’s the balance? How much does politics determine what gets done, and how much is it just the idea that this would be the right policy for the American public?

Azar: Mike Leavitt, who was the secretary when I was deputy secretary, he had a phrase, and I’ll probably mangle it, but it was essentially, “Facts for science, and politics for policy.” And it’s important to remember this distinction. So, facts are facts. You gather data. We are especially a data-generating agency. But on top of that are policy overlays. And there are choices that are made about how do you use those facts? What do those facts mean? What are the implications? The United States Constitution vests under Article 2 in the president of the United States to make those choices and, as his delegee, the secretary and the other appointed leaders of the department. So there’s often this notion of politicizing science, but it’s, are there facts? Facts are facts. You generate facts. But what are the implications for policymaking? And I don’t think there’s anything illegitimate — I think is completely appropriate, whether a Democratic or Republican president — that you look and you consider all kinds of factors. Because for instance, for me, I’m going to look at things very much from a public health lens as I assess things. The secretary of the treasury, the secretary of commerce, may bring a completely and important different perspective to the table that I don’t bring. And it’s completely legitimate that that gets factored on top of whatever I or other agencies bring in as fact. So I think it takes some nuance and that we often, frankly, in public discourse don’t catch nuance. Interesting. We don’t do nuance well.

Rovner: We don’t do nuance.

Sebelius: Well, I would agree with the description of the facts versus the policy. And policy does often have political flavors. I was fortunate to work for a president who said, meant, and said it over and over and over again that he would follow the science. And he did. And I had interesting political debates with people around him, on his team, about what should be done, “rewrite the guidance on this,” “do that,” “this is going to upset this group of people.” And he was very resilient and very consistent, saying, “What does the science say? What do the scientists say? That’s where we’re going,” on those areas which were really defined as giving advice to the American public on health issues, doing a variety of things. I mean, he was totally focused on listening to the science. The politics came in, as I think Secretary Azar said well, in some decisions that were brought to him, which really involved often battles between Cabinet agencies, and both were very legitimate. Again, we had pretty ferocious battles on food labeling and calorie counts and how much sodium would, should manufacturers be allowed to put in all of our manufactured goods. I’m sure many of you are aware, but, you know, American sodium levels are just skyrocketing. And it doesn’t matter what kind of salt you use at your table; it’s already baked into every loaf of bread, every pat of butter, every can of soup. And a lot of European countries have done a great job just lowering that. So the goods that are manufactured that you pick up in an EU country — Kellogg’s Corn Flakes has a third of the sodium that the Kellogg’s Corn Flakes that you get in Aspen does, just because that was a choice that those governments made. That’s a way to keep people healthy. But we would come at that through a public health perspective and argue strenuously for various kinds of limits. The Department of Agriculture, promoting farm products, supporting goods it exports, you know, not wanting to rile people up, would come in very strongly opposing a lot of those public health measures. And the president would make that call. Now, is that politics? Is it policy? Is it, you know, listening to a different lens? But he made the call and some of those battles we would win and some we would lose. But again, it’s a very legitimate role for the president to make. He’s getting input from leaders who see things through a different lens, and then he’s the ultimate decider and he would make the decision.

Becerra: So um, I’ve done politics and policy much longer than I’ve done the secretary role. And I will tell you that there is a big difference. We do do some policy, but for the most part we execute. The policy has been given to us by Congress, and to some degree the White House will help shape that policy. We have some role in policymaking because we put out guidances, and the guidance may look like it’s political or policy-driven, or we decide how much sodium might be allowed in a particular product and so forth. But for the most part, we’re executing on a policy that’s been dictated to the agencies by Congress. And I love that, because when I became AG in California, it really hit you how important it is to be able to marshal facts. And in HHS, it’s not just facts; it’s scientific facts. It is such a treat, as an attorney, to get to rely on scientific facts to push things like masking policy in the face of some hostility that went throughout the country to the point that our CDC director had to have security detail because she was getting death threats for having policies that would urge society to have masking policies for adults, for children. We do rely principally on science and the facts at HHS. Maybe folks don’t believe it, but I can put those on the table for you to take a look at. And perhaps the best example I can give you, and I don’t know if I’ll have time to connect the dots for you, because it’s a little esoteric: Title 42, which many of you got to hear about all the time in the news. Title 42 was a policy that was put in place under the Trump administration when we were in the height of the covid pandemic. We didn’t know what was causing covid, so we were trying to make sure that we protected ourselves and our borders. And so therefore, for public health reasons, we sort of closed our borders to the degree that we could, except for those who proved that they had gone through steps and so forth to be able to come in. Title 42 was used under the Trump administration, under the Biden administration to stop people from coming through our southern border. And there reached a point where, as things got better, our team said Title 42, which is health-based — it’s to stop the spread of contagion — was no longer the appropriate tool to use at the border, because we were letting people in the northern border, by plane, and all the rest. You just had to go through protocols. And so they were saying for health care reasons you go through protocols. But Title 42 is probably not the blanket way to deal with this issue, because it’s no longer simply a health care issue. We pushed really hard on that within the administration to the point where, finally, the administration said, “We’re pulling down Title 42.” Then the politics and the policy came in, from Congress saying, “Oh, how dare you take down Title 42? How dare you do that and let the flood of people come into this country?” Well, look, if you want to deal with people coming into the country, whatever way, then deal with our country’s borders through our immigration laws, not through our health care laws. Don’t try to make health care experts be the reason why you’re stopping someone from coming into this country. Stop hiding behind their skirt. And that’s where we went. And the administration took that policy as well. They took the policy. We then got sued and a court said, “No, you will not take down Title 42.” Ultimately, we think we were going to prevail in court, but ultimately, because we pulled down the public health emergency, things got better under covid, we no longer needed Title 42. But just again, to be clear, the women and men at HHS, we execute; we use the facts and the science. We don’t do politics.

Rovner: So we’ve been very serious.

Becerra: Not everybody believed me on that one.

Rovner: I know, I know. We’ve been very serious here for 50-some minutes. I want to go down the line. What’s the most fun thing you got to do as secretary or the coolest thing that you got to do as secretary?

Azar: Probably for me, it was the trip to the Congo, you know, being in the DRC, going to Uganda, going to Rwanda, flying on MONUSCO [United Nations Organization Stabilization Mission in the Democratic Republic of the Congo] U.N. peacekeeping forces; there was a Russian gunboat taking Tedros and Fauci and Redfield and me there into this war zone. I mean, it’s a once-in-a-lifetime — it’s sort of crazy — but once-in-a-lifetime thing that had impact.

Rovner: I don’t know that most people would call that fun.

Azar: I mean, it’ll be one of those great memories for life. Yeah. Yeah.

Sebelius: There were certainly some great trips and memorable experiences around health results in various parts of the world. Some martinis on the presidential balcony and looking at the Washington Monument — that’s pretty cool at night. But my, I think, personally kind of fun thing. I raised my children on “Sesame Street,” and they loved “Sesame Street” and the characters, and that was sort of part of the family routine. And so I got to go to “Sesame Street” and make a public service commercial with Elmo. I got to see Oscar’s garbage can. I met Snuffleupagus. But the Elmo commercial was to teach kids how to sneeze because, again, we were trying to spread good health habits. And so the script said — I mean, Elmo is right here and I’m here — and the script said, “OK, Elmo, we need to practice how to sneeze. So put your arm up and bend your elbow and sneeze into your arm.” And the puppet answered, “Elmo has no elbow.” That wasn’t part of the script. It was like, really? “And if Elmo does that, it will go like this: Achoo!” OK, so we flipped the script and Elmo taught me to sneeze. But that was a very memorable day to finally be on “Sesame Street.” It was very cool.

Rovner: OK, beat that.

Becerra: My team has not yet scheduled me to go on “Sesame Street,” so it’s going to be tough.

Sebelius: But just remember, Elmo has no elbows, if you get to go.

Becerra: I think probably what I will think of most is that I had had a chance to be in the White House and meet with the president in the Oval Office and the rest as a of member of Congress and so forth. When I went in, and it was because things were kind of dire with the kids at the border, and I knew I was going to get a whiplash after the meeting — it wasn’t fun at the time, but walking out, you know, it’s the kind of thing you think of, you know, “West Wing” kind of thing. You actually got the — president sat at the table, I was the guy that sat across from him. Everybody else was to the sides. You know, for a kid who was the first in his family to go to college, Dad didn’t get past the sixth grade, Mom didn’t come here till she was 18, when she came from Guadalajara, Jalisco, Mexico. It was pretty cool.

Rovner: So I could go on all night, but I think we’re not supposed to. So I want to ask you all one last question, which is, regardless of party affiliation, what is one piece of advice you would give to a successor as HHS secretary? Why don’t you start?

Becerra: Gosh, don’t start with me because I’m still there, so —

Rovner: All right.

Azar: I’m going to plagiarize and I’m going to give you the advice I wish Donna Shalala had given me before I took the job. But I would give it to any successor, which: She told me, “Do not take the job unless you have authority over personnel. Refuse to take the job unless you have control over who’s working, because people is policy and you have to be able to control the ethics, the tone, the culture of the organization. And people are that, and you need to have that authority.” And ever really since the Reagan administration, the Office of Presidential Personnel has just been this vortex of power that controls all political appointees at Cabinet departments. And I think if the president really wants you, you need to strike a deal that says, at a minimum, I’ve got veto or firing rights.

Sebelius: I think my advice would be the advice you give to a lot of employees who work in the private sector or public sector is, Make sure you’re aligned with the mission of the CEO, so in this case the president. I mean, don’t take the job because it’s cool and you’ll be a Cabinet member, because then it will be miserable. And with HHS, recognize the incredible assets across this agency. It is the most dazzling workforce I’ve ever had an opportunity to be with — the brightest people of all shapes, sizes, backgrounds, who taught me so much every day — and just cherish and relish your opportunity to be there, even for a short period of time. It’s miraculous.

Becerra: So I’d agree with Alex: Assemble your team. And it really is, because Kathleen mentioned it, it’s a very small group that actually you get to bring in, or even the administration gets to bring in, because most of the folks are civil service, so it’s only a fraction of the people that are going to be new. But your inner circle, the team that’s going to sort of be there and guide you and tell you what’s truth, they’ve got to be your team, because someone’s got to have your back. But I’d also say, know your reach, because as Kathleen said, this is not the Azar administration or the Sebelius administration, the Becerra administration. It’s the administration of the guy who got elected. And at the end of the day, the president gets to make the call. So as much as you may want to do something, you’ve got to know your reach.

Rovner: Well, I want to thank you all. I hope the audience had half as much fun as I did doing this. Let’s do it again next year. Thank you, all. OK, that’s our show for this week. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left a review; that helps other people find us, too. Special thanks, as always, and particularly this week, to our producer, Francis Ying. Also as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can tweet me. I’m @jrovner. We’ll be back in your feed from Washington next week. Until then, be healthy.

Credits

Francis Ying
Audio producer

Emmarie Huetteman
Editor

To hear all our podcasts, click here.

And subscribe to KFF Health News’ ‘What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).